Since about 2010, I have considered the non-surgical treatment of hip impingement and labral tears to be one of my clinical specialties as a physical therapist. Since then, at least 50% of my patients are hip patients. Many of these hip patients are also dancers or CrossFit athletes.
With all of these individuals I have noticed many similarities in their stories, so I thought I would share my own. Sometimes just knowing that your situation is not weird or rare, can help ease anxieties. Of course, each story is unique and influenced by various factors, but mine is not so atypical. Warning ... long story ahead.
Check out this e-book if you have an interest in seeing what exercises might be helpful for folks with hip impingement.
I grew up a ballet dancer.
At age 3 my parents placed me in dance classes and I thrived. Always outgoing as a kiddo, I learned some social awareness for when it was appropriate to perform and when it was less-so. Very rigid rules. No gum. No yawning. No talking in class. No patterned leotards or skirts. And no letting your bum stick out.
I'm not kidding.
Tucking your rear under you and forcing a posterior pelvic tilt as well as an anterior positioning of the hips was normal and encouraged.
It is aesthetically pleasing to the ballet eye. It is not uncommon to see a ballet instructor come up behind a student and tuck her pelvis down and under, pushing the top of the hip bones forward.
I remember spending so much time in this position (left), trying to increase the mobility of my hips. I wanted to make my already extreme turn-out even more extreme. To reiterate, this was all normal and encouraged.
Now, I had the genetic propensity to be a good dancer because of the bony architecture of my hip joints. (I am naturally gifted with "good" turnout. For you anatomy geeks out there, I am retroverted.) I also have a natural hypermobility in many of my joints. These things are rooted in genetics. However, I also believe that during my development, I contributed to my flexibility and in essence created too much motion because I was so motivated to be a good ballet dancer and stretched excessively into these positions. So we have nature (genetics and hip anatomy) and nurture (my excessive stretching and a culture that encouraged it).
I danced at a very high level until the age of about 18. I thought of nothing else - I spent all my money and time on classes, dancewear and point shoes - at over $50 a pair, I was going through a pair a month just about because I was dancing so much. I danced until I was 25, and truly that was a very important piece of who I was then and helped to shape who I am today.
I distinctly remember that my hips felt "stiff" - and they sort of ached all the time. But, as a dancer that was normal, right? I mean I was dancing 6 days a week for about 3 hours a night. Working hard required some amount of pain in order to see results (that was my thinking at the time). But, I do remember that there were times my hips would "clunk", "click" or "pop" and I never said anything to my instructors or other dancers, assuming that was just normal. And sometimes it hurt! If nothing else, it was a creepy feeling. A big lunking pressure in my hip, especially with grand rhond de jambe en l'air.
Fast forward eight years to when I was a 2nd year physical therapy student at the University of Washington. We were learning about hip impingement and I literally though to myself:
"I have that!"
The instructor was listing the symptoms of hip impingement:
stiffness in the thigh, groin, or hip
deep aching in groin or buttock
sharp pain in the groin or buttock when the thigh is moved close to the body beyond 90°
sharp pain in the groin or buttock when the thigh is moved across the body toward the opposite shoulder
pain with sitting for long periods of time
difficulty with weightbearing on the affected leg
hip pain at rest and/or with activity
hip pain during and/or after sexual activIty
pain during or after sports
low back pain and/or sacroiliac joint pain
pain that comes and goes
I had all of these symptoms...
And, though I wasn't really admitting it, even to myself, I was noticing that I was experiencing a decrease in hip range of motion and flexibility in the dance studio. After about 8 years of pain and "weird" feelings in my hip, the symptoms were worsening. Things were feeling stiff and sluggish and even as a PT student, all I knew to do was stretch.
So I did nothing about it... and kept dancing. And kept stretching ... Sound familiar? If you have read this far, it is likely that your story is similar. Or at least you have felt those symptoms listed above.
Another year goes by without me taking action.
By this time it is 2007, I am newly graduated from PT school and just spent the month of June studying 8 hours a day for my boards. We are talking: sitting, hunched over books and anatomy models in a hard chair ... my hip would be so sore after those study days. I had also taken up running in this last year when I was away from Seattle on my physical therapy internships and was unable to dance as much.
Following my licensing exam, I had about week left before my first job as a PT was to start so my now husband (then boyfriend) and I went on a multi-day backpacking trip in the Leavenworth, WA area. Oh boy .... I learned over those few days that I could not tolerate pounding for miles and miles at a time with weight on my back. I felt weak, sore, frustrated and no amount of ibuprofen helped. I was a miserable backpacking partner that trip.
long road ahead
So, at this point I knew something needed to change. The next series of events was a process of self-discovery regarding medical intervention and activity modification. And, unfortunately I had to figure a lot of my rehab out on my own. Here's what happened:
September 2007: I decide to do physical therapy for my hip finally. Myofascial release and massage helped, but hip flexor stretches made things worse as did hip mobilizations. I think the exercise prescription was generally good and well-intended, but as a dancer with butt-tucking tendencies, I fooled my PT into thinking I was using my glutes when I really wasn't. No significant change in symptoms.
January 2008: MD visit and x-ray. "Negative" for significant findings. No suggestions as to what to do next.
Feb 2008: series of acupuncture appointments. No change in symptoms.
Spring 2008: quit ballet. One of the hardest decisions I ever made because at this point I had been dancing for 20 years. But years of pain and a struggle with eating behaviors made this the right choice. Not an easy option for many dancers...and a conversation that I have with patients on a daily basis. Not asking them to quit, but really reminding them of the impact their activity is having on their condition.
Summer 2008: added in yoga classes (not hot) and started training for the Seattle Half Marathon. Symptoms continue.
Early Fall 2008: did a 17-mile day when training for the Seattle Half (over achiever, novice runner mistake)At about mile 15, had searing pain in the left hip and limped home. Wasn't able to continue training. At this point, not exercising outside of yoga once a week. Symptoms continue.
Late Fall 2008: began hot yoga three days a week. Felt great in the moment and absolutely horrible later in the evenings or the next day. Symptoms worsening.
Winter 2008: Asked MD to order an MRI and results were "negative" for labral tear. Referred to Dr. James Bruckner in Bellevue, WA. He noted that I had "clear" bony femeroacetabular impingement in my hips (per that previous x-ray that was "negative" for significant findings) and that I "absolutely" had labral tears. Surgery was recommended. He also reminded me that there is a 40% false-negative rate for acetabular labral tear upon MRI testing so regardless of this "negative" finding, he felt certain I would show tearing if they went in surgically.
Winter 2008: started taking body pump classes - felt that I needed some strength training but didn't know where to start. Did this 3 days a week with no increase in symptoms. Basically, this is light weights set to aerobics music. Interestingly, I learned how to correctly hip hinge! Crucial. (Even as a PT who taught these positions, I was unable to correctly achieve them myself!)
Spring 2009: started PT again, with a focus on Muscle Activation Technique. Decreased symptoms but still clear weakness.
Summer 2009: Becoming clear that strengthening was feeling better than stretching and mobilizing. Signed up to work one on one with a personal trainer. Did this and spin classes for 2 years and symptoms gradually improved. Continued with hot yoga here and there.
Phew - if you've made it this far, you can probably relate to the length of time someone with FAI deals with symptoms, the frustration felt, and the desperation to try any and everything for relief.
Winter 2010: joined CrossFit with an emphasis on strength training. Learned to feel comfortable under a weighted barbell, learned to squat, learned that building muscle made me feel better. Pretty much forgot I had an eating disorder.
Spring 2011: flare of symptoms (no clear reason why) and obtained a fourth opinion from Dr. Doug Nowak in Everett, WA when I started having sacroiliac pain in addition to the hip pain. Same thing. "Yes, you are a candidate for surgery." But, let's try cortisone injections to the hips and see if this helps with pain. Started wearing a sacroiliac belt for stability and felt relief with this.
I continued to decide against surgery because parallel to this timeline, I was beginning to treat a lot of dancers with hip impingement. I was observing very mixed results in the patients who were coming to me after surgery. Not enough positive outcomes for me to choose surgery when I still had so much strengthening to do. Additionally, we do not have long-term data to determine how patients who did have surgery compare with those who didn't. I even had a few patients who said they were worse and wish they had never undergone the procedure. Ugh! What to do!?
Winter 2011: Finally obtained cortisone injections. Statistically, cortisone works about 50% the time for hip impingement. As we would expect, the injections worked in one hip and not the other. But, having reduced the pain quite a bit, they bought me time to continue to train my hips correctly in CrossFit and I completely eliminated stretching of the hips. As in, I don't do it! I might stretch my glutes a little with a figure 4 pose or use a lacrosse ball to my buns, but you will never see me in a forced lunge or pigeon pose stretching out my hip flexors. You see, I learned that a tight and painful muscle isn't always a short muscle and for me in particular, stretching the hip flexors only made my symptoms worse.
Fall 2012: spent the next 8 months studying several hours a week for a competitive PT board certification. Ouch. Increased symptoms.
Winter 2012: Kept up with my strength training. Quit yoga.
if you read that long timeline, its most likely because you see similarities in your story. But, The details are just as crucial as the take away:
Essentially, I feel the take away message is that this takes time ... a lot of time ... but you CAN feel better!
The details: stop stretching, start strengthening!
By the time 2013, rolled around, I had been having hip pain for 15 years. I was 30 and had been doing weight training for 4 years and CrossFit for 2. I hadn't danced in 5 years and hadn't done yoga in over a year. Honestly, I felt better than ever. And, this has continued to be the case!! The reality is that I do not have hip pain regularly any longer. Today, 9 years have gone by since I stopped dancing and stretching. That, combined with 8 years of strength training has really changed my symptomology. And who, in a million years, would have thought this ballerina would be weight training and CrossFitting? Ballerina gone Rogue! I do have pain from time to time but its really manageable and I know what not to do, what positions bother me, what kind of volume or repetition I can take in my training and what recovery needs to look like. I have realistic expectations of my future as an athlete and I have very strong convictions about how to treat hip impingement patients in the clinic.
Let's be clear, this is my story only. However, I will be honest, far too many dancers leave the dance studio only to find themselves in a hot studio "winning" at yoga - they are so flexible and it feels good in the moment. But, I wish they would reconsider. I wish I had found strength training (and my booty) earlier in life. Not only do my legs look better, I literally FEEL BETTER! No need to become a CrossFit athlete or squat over 200#, but please commit to learning to hip hinge and getting out of your butt-tucking behavior. I can help you. I have lived it, I have treated a lot of patients who have these conditions and I know the strategies which help the most!
Educating my patients about this process and helping them to manage their expectations of recovery is crucial because this takes a long time. It takes time to build new motor patterns and to strengthen. It takes time to wrap your head around changing your behavior or walking away from things that cause pain if that is necessary. Its overwhelming when you find out that many believe your condition warrants surgery ... but then you later find out that often the surgeries do not relieve a person of pain or dysfunction.
If you are struggling with hip pain or have been diagnosed with FAI or labral tears, if you feel hopeless, overwhelmed or confused, please feel free to email me us firstname.lastname@example.org so we can discuss your specific situation and get you on a path to healing and back to living an active and pain-free life. Please also consider scheduling a virtual appointment with me if you are not in the Seattle area. Additionally, this e-book may suit your needs as it is full of helpful information and exercises!!
In good health, S
"Sarah is a miracle worker! Two years ago I had three different surgeons tell me I needed surgery for a labral hip tear. I was in so much pain that I couldn't even do normal daily activities and definitely couldn't keep up with my 3 little kids. I saw Sarah for the first time just a few weeks before my scheduled surgery and she immediately had me start on mobility, strengthening and neuromuscular re-education exercises. I ended up canceling the surgery. After five months of dedicated work with Sarah, my pain was gone and I was able to be completely physically active. I'm so grateful for her exceptional care - she gave me so much knowledge that I'm able to stop flare ups and since I'll have the hip issue for my whole life, that is priceless. I would absolutely recommend seeing Sarah - especially if you have any hip/labral tear pain."
-Yelp Review 2016