When I was twenty-six, my hip problems became obvious. Lifting my leg up and over the edge of the bathtub to take my nightly shower caused sharp snapping in both my hips. I’d wake up every morning with aching in my hips and burning in my feet and calves. Sitting for long periods would create a sense of gnawing friction in my joints, and my ischial tuberosities felt somehow under-padded all the time. Then an old unwanted visitor returned: left knee pinching and weakness.

It got to the point that bending over to tie my shoes made my back ache and I felt as if I might rupture my hip joints. A cacophony of popping and snapping accompanied hip flexion and extension as well as rotation. A bleak future lay before me – one with a lot of pain pills or surgery or both. Since I have many friends who had opted for joint surgeries with results that I would hardly call “successful,” I started looking for alternative answers.

Years of trial and error – of stretching, smashing, and strengthening – allowed me to return to hockey, lift weights, and generally enjoy my life again. My recovery is why I strongly believe that hip impingement is a problem that needs to be addressed muscularly and not surgically. In addition, a long history of well-intentioned but unproven (and/or ultimately discredited) surgical procedures makes me skeptical in general of surgical fixes for joint issues like hip impingement.

If you have not heard of femoral acetabular impingement (FAI), here’s a brief summary of the current medical view. It is believed to be a defect of bone shape that you can see in an x-ray. The acetabulum, the femoral head, or both are misshapen, and this leads to a decrease in joint range of motion (ROM). Someone with FAI will be restricted in flexing his hip joint or internally rotating. The bony malformations lead to bone-on-bone contact that grinds away at the labrum in the hip joint. This leads to arthritis and eventually the need for total hip replacement.

FAI is diagnosed when someone has pain somewhere in or around the hip, his ROM is decreased, and there is x-ray and/or MRI evidence of FAI. For FAI to be a valid diagnosis, the pain, the ROM, and x-ray and MRI evidence should all add up.

It Doesn’t Add Up

In fact, none of the diagnostic criteria add up. There are four main points you need to know about FAI:

1. X-ray diagnosis of hip impingement means nothing. You can have x-ray signs of hip impingement with absolutely zero symptoms. In a study by Hack et al. (2010), researchers examined 200 people with no history of hip problems. Fourteen percent had cam impingement (this is when the femoral head is believed to be not spherical enough to articulate correctly) in their hips.
2. MRI diagnosis of hip problems means nothing. You can have MRI signs of hip problems and no symptoms. In one study (Silvis et al. 2011) of thirty-nine hockey players with zero symptoms of hip pain and discomfort, 77% of them showed signs of hip/groin pathology. They had problems in the MRI but no problems in real life.
3. This one is very, very important: there isn’t even a correlation between ROM, pain, and hip impingement in an x-ray. In a study by Weir et al. (2011), a group of researchers took patients with longstanding adductor/groin pain and did some ROM tests and then compared these with their x-rays. There were a total of sixty-eight hip joints to assess (two per person), and 94% had x-rays that had indications of FAI. If the theory is that x-rays are useful in diagnosing FAI, then researchers should have seen the classic movement problems associated with FAI. They didn’t. Only nine hips tested positive in the anterior hip impingement test. Here’s a quote from the study: “There was no relationship with the number of radiological signs. There was no correlation between hip ROM and the number of radiological signs.”
4. There is no proof that surgery to correct FAI now does anything to prevent the necessity for further surgery later. In one study (Philippon et al. 2009), 112 people underwent surgery to address FAI. Ten of those patients (9%) underwent total hip replacement within twenty-six months.

There is no correlation between any of the proposed diagnostic criteria and symptoms. If the bony malformations are supposed to be the cause of the problem, there should be at least a moderate correlation between the x-ray evidence of FAI and movement problems, but there are none. In fact, I’ve personally heard multiple anecdotes of an individual being told that his non-painful hip is the one with more advanced signs of FAI in an x-ray.

How Should We Look at the Problem?

It makes far more sense to consider the activity of muscles. The muscles are, without question, the physical drivers of movement. The way the muscles are recruited and their ability to contribute appropriately to any given movement very clearly affects motion at any joint.

If you were to remove one head of the biceps brachialis of your right arm, would you expect to be able to flex your elbow with the same ease, ROM, and strength as on your left? Clearly not! If you were to inject a chemical solution into one head of the biceps brachialis to paralyze it so that it atrophied over years, could you reasonably assume the kinematics of your elbow and shoulder would be affected? Absolutely.

The hip joints are wrapped with twenty muscles on each side that directly affect the stability and mobility of the joint. Imagine that you injected that paralyzing solution into the hamstrings and gluteals and rarely allowed your hips to move a range beyond 80° of flexion. Would that negatively affect your hips and your general comfort level? Yes. And while many a modern-day worker doesn’t use a chemical solution to paralyze muscular activity in his butt and the back of his legs, he certainly uses a chair to the same effect on a very regular basis. There are, of course, plenty of other ways to throw off hip joint kinematics: a muscle pull, overtraining a muscle group to the point of overpowering imbalance, or poorly chosen stretching habits could all impede healthy movement.

What We Can Do

What can a Rolfer generally do to help this situation? We need to restore balance to the joint. For men – especially athletic men – typical areas of concern will be the adductors and the quads. These muscles can be overdeveloped and overused, limiting the person’s ability to rotate the hip joints and also locking the pelvis in an anterior tilt (which, incidentally, is known to reduce the range of hip flexion).

Figure 1: Frog position for adductor work

Adductor work should be done with the client supine in a frog position (Figure 1) or in a position that allows you to work the adductors in an abducted position. A typical Fourth Hour of Rolfing® Structural Integration does not provide an opportunity for the muscles of the hip joint to learn to accept a novel position as it is too close to a normal standing position. We want to create new opportunities for joint ROM, so simply keeping things in ‘standing’ is hardly productive. The quad work can be done with the client supine as you would in a typical Fifth Hour. Pay special attention to the proximal attachments of the quads and to the lateral quads.

The gluteals and the TFL and IT band can also be stiff to the point of locking up joint rotation and flexion. Therefore, it’s a good idea to check to see what hot spots you can find in their connective tissue. One thing to note, however, is that these muscles are often the ones that have been ‘paralyzed’ for years. Trying to get them to relax more and more may be detrimental to your client. Sometimes a little tissue work is all that is necessary to unlock a little motion, and more may have a negative effect. I find this is most common with women, though it certainly is not exclusive to them. Women tend to be more flexible (particularly those who have focused for years on yoga) and can be very weak in their posterior and lateral hip musculature. Doing tissue work on the gluteals can often be completely useless or even make a weak client worse. If you find that happens with a client, whether male or female, your best bet is to refer out to someone who can do solid exercise training to help reestablish strength and coordination in the atrophied muscles of the hip, rather than attempt to push harder or with more ferocious intention.

Because of the complicated relationships between the many muscles of the hips, FAI (if we want to still consider it a discrete disease) can take a long time to resolve and requires the client to be actively engaged in his path toward better movement. There are no quick fixes and no magical solutions to the problem. The way out requires trial, error, and the willingness to continuously retrain the hip musculature to play nice and move well. Tissue work on the adductors, quads, and sometimes the gluteals can be a very ‘helpful hand’ for a client who’s walking the path back to full hip health.

Matt Hsu has spent almost a decade experimenting and rehabbing his own hips so that he is be able to play hockey, hike, and lift weights again. He is the author of the “Healthy Hips” ebook, a guide for restoring a base level of flexibility and strength (available at www.uprighthealth.com/product/healthy-hips), and is co-creator of “The FAI Fix,” a comprehensive ebook and video resource to help people solve their own hip problems nonsurgically (available at www.thefaifix.com).

Bibliography

Hack, K., G. Di Primio, K. Rakhra, and P.E. Beaulé 2010. “Prevalence of cam-type femoroacetabular impingement morphology in asymptomatic volunteers.” Journal of Bone & Joint Surgery (Am) 92(14): 2436-2444.

Philippon, M.J., et al. 2009. “Outcomes f o l l owig h i p a r t h r o s c o p y f o r femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up.” The Journal of Bone & Joint Surgery (Br) 91(1):16-23.

Silvis, M.L., et al. 2011. “High prevalence of pelvic and hip magnetic resonance imaging findings in asymptomatic collegiate and professional hockey players.” American Journal of Sports Medicine 39(4):715-721.

Weir, A. et.al. 2011. “Prevalence of radiological signs of femoroacetabular impingement in patients presenting with long-standing adductor-related groin pain.” British Journal of Sports Medicine 45(1):6-9.Why the Medical Explanation for FAI Doesn’t Make Sense …[:]