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Lindsey is a PT and also competed as a 4-year scholar-athlete playing soccer. Furthering her career she became a board-certified Orthopedic Clinical Specialist in 2016. She then completed the University of Chicago Medicine Orthopedic Manual Therapy Fellowship in 2019. Her clinical and research interests include treating runners and triathletes, people with chronic and persistent pain, and people with femoroacetabular impingement (FAI) syndrome. She is an avid marathon runner and long-course triathlete and It was her own hip journey with FAI and a labral tear that sparked her interest in helping others with hip issues get back to doing the things they love. We dive into the definition, pathology and clinical signs of FAI along with the likely contributing factors in running. Brodie and Lindsey also discuss the prevalence of incidental findings with MRI scans and the asymptomatic prevalence within the healthy community. Lindsey also shares the common misconceptions about this condition, rehabilitation advice and treatment. We also answer your patron questions including the risks of running with FAI and the likelihood of developing other running-related injuries if untreated. Instagram is: @plassptperformance website: plassptperformance.com email: lindsey@plassptperformance.com Become a patron! Receive Run Smarter Emails Book a FREE Injury chat with Brodie Run Smarter App IOS or Android Podcast Facebook group Run Smarter Course with code 'PODCAST' for 3-day free trial.
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On today's episode, Understanding FAI and Label Tears with Lindsay Plass. Welcome to the Run Smarter podcast. The podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger, smarter runner. If you're like me, running is life. But more often than not, injuries disrupt this lifestyle. And once you are injured, you're looking for answers and met with bad advice and conflicting messages circulating the running community. The world shouldn't be like this. You deserve to run injury free and have access to the right information. That's why I've made it my mission to bring clarity and control to every runner. My name is Brodie Sharp. I am a physiotherapist, a former chronic injury sufferer and your podcast host. I am excited that you have found this podcast and by default become the Run Smarter Scholar. So let's work together to overcome your injury, restore your confidence and start spreading the right information back into your running community. So let's begin today's lesson. Happy New Year everyone, I have another exciting episode for you. Hopefully you have recharged your batteries. I know I have, I've just been away at the beach for the last week or so, and I've come back and time to start recording. I've got some big, exciting goals for 2022. The book is one of them, which I'll keep you updated on, but I have a few other business ideas or content creation ideas which are up my sleeve which I won't disclose just yet. I'll keep you hanging for those. Today we have Lindsay Plass. I have a little bit of a bio on her. Let me just pull that up and get you guys familiar with Lindsay before we bring her on. So Lindsay is a PT and also has competed as a four-year scholar athlete playing soccer. She had furthered her career and became, furthered T career and became a board certified orthopedic clinical specialist in 2016. She then completed the University of Chicago Medicine orthopedic manual therapy fellowship in 2019 and her clinical and research interests include treating runners and triathletes, especially people with chronic and persistent pain and people with femoral acetabular impingement or FAI syndrome. uh, with or without label tears. So she is an avid marathon runner and long course triathlete. And it is her own hip journey with FAI label tears, which sparked her interest in helping others with the same hip issues and returning back to the sports they love. I'm not sure why I haven't done a hip issue or a hip FAI label tear episode in the past, but Lindsay is a perfect person to have on. We have a very detailed discussion. I think it's a little bit technical at the start, but definitely hang in there because it gets very interesting. A lot of misconceptions around this particular condition and how it's treated. So it's right up the alley in the run smarter podcast episodes and can't wait for you guys to hear it. So let's take it away. Lindsay Plass, thanks for joining me on the podcast today. Hi, thanks for having me. I am. Not too sure why I haven't had a podcast episode on FAI and label tears before, because I know a lot of people have been asking for it. I think the, I don't really consider it as a running condition, but a lot of runners have it. And so, um, I'm glad that you're on here. I listened to you on another podcast and thought I need to have you on pretty much for your expertise, but also your backstory as well. So for those who aren't familiar with you, do you mind sharing who you are, where you're from? And. your experience, um, with this particular condition. Sure. So like you said, my name is Lindsay Plass. I'm a physical therapist. I live in Chicago, Illinois. And I think, um, the kind of thing I didn't anticipate when I was going through my physical therapy schooling was that one day I would, you know, actually become a patient. Um, so it's kind of when I found out that I had this hip with Thumbel Acetabular Impingement and a Label Tear, which we'll get into in a little bit what that means. But that really changed the trajectory of my career as a physical therapist and has really given me kind of this unique ability, I think, to relate to other people who have it too. So I think the thing is about Thumbel Acetabular Impingement, which we can refer to as FAI. is that yes, a lot of runners have it, and it's very common, but it's not always the reason someone is having pain. And so I think that that's something that can be helpful for runners to understand, that just because you may have a hip that has FAI, with or without a label tear, that's not always... you know, something that's going to cause you pain or something that means you have to stop running. Yeah. Where, how far into your, like, how old were you when you first started noticing these particular symptoms and like what sort of activities were you participating in? Yeah, so I graduated college back in 2009, and I played soccer at a Division III school in Wisconsin called Carthage College, and had no issues really, never really had any hip pain. And then after college, got into marathon running. And you know, within the first five years after college... I ran six marathons. I had this goal to qualify for the Boston Marathon. Each race was getting closer and closer to that goal. And then in the meantime, I started my physical therapy schooling and graduated from Northwestern University in 2012. And then it was actually, I ran the Chicago Marathon that year, 2012. And then it was in 2013 that my hip had started hurting. So it was really like a novice clinician. It was within the first year or two of graduating PT school. And so this was about seven years ago. And I think the really cool thing, though, is that research and awareness on FAI and label change for the better. I think when I was going through this, there was not a lot of information out there. And so I think when I say that it changed the trajectory of my career, I think that part of what I've been able to do is kind of help spread awareness about FAI label tears and how runners that have hip... Would these conditions can still continue to run and do marathons and do whatever sport they like? I totally agree with you because when I graduated from physiotherapy, it was 2012 and we had, if you want to be a private practice physio, we had this textbook, which was, um, Brooklyner and Khan, um, clinical exercise, something or other, and, um, Peter Brookner was the author and I think it was maybe the 2012 edition didn't even have like FAI as a condition within that textbook. And it wasn't until the later edition, I think they brought out the later edition the following year, which did include FAI, but still that's 2012, 2013 that it wasn't even in this textbook, which we considered like the Bible for private practice physiotherapy. It had like all these conditions, exactly how to treat it, how to rehab it, what the management looked like and just didn't exist in the previous edition of that textbook when I graduated. And so totally agree there was very little awareness and glad that, you know, science and the awareness has now developed to the point where it is today. So I guess with these two conditions, this FAI and the labral tears, do you mind maybe explaining to the runners exactly? what it is and what I guess what the pathology involves. Yeah, so FAI stands for femoral acetabular impingement. And then now we describe people with symptomatic FAI. So these are people that have hip pain. They have imaging findings that show the FAI. And they have with the clinical exam, so when the therapist is doing certain maneuvers with the hip, that produces their pain. Specifically, there's a test called the FADR test, F-A-D-I-R, where the therapist bends up the hip and internally rotates it, putting pressure on the groin. And that's one of the clinical signs that someone may have FAI and a labral tear. And so now they're describing symptomatic FAI as FAI syndrome. So I think this is important because statistics show that close to 70% of people can have FAI and may not know it and may not have pain. So I think a lot of the research and clinical applications have evolved to where we're starting to decipher between symptomatic FAI. and people who just happen to have it but don't have pain. And then there's further subcategories. So there's different kinds of hip impingement that can occur. So one kind of hip impingement is called cam morphology. And so that's when you get changes to the head of the femur, which is the thigh bone. And so you get kind of this. overgrowth of the bone on the head of the femur. And another, you know, interesting thing that's evolved over time with the research is even now really delineating between primary cam morphology, which means that it just happened to occur during, you know, skeletal maturation as a physiological response, and then secondary is actually related to when someone may have had an acute trauma or a fracture to the hip. And then the second kind of hip impingement involves pincer morphology. So this means you get over coverage of the femoral head by the acetabulum or the socket part of the hip. And now actually it's common that people can have both. So like when I had my MRI, it showed that I had both CAM and PINCER morphology. Hmm. I think it's good to, I guess, um, highlight a few of these terminologies. So when you're talking about the FAI, so the femoral acetabular impingement, so the, the femoral refers to the femur and you, Nicely described as like a ball and socket joint. So the hip is like a ball and socket. And if someone were to, I guess, like make a fist that represents the ball and then place your other hand, like covering that fist to represent the socket, what we're talking about is like an impingement in there somewhere. There's been some overgrowth in one of those, either the ball or the socket, which leads to that particular impingement. And so what you're saying is there's two different types as the cam, which is If you had that making the fist and the ball and socket, it's actually the ball in the ball and socket that has some sort of maybe bone overgrowth. But the pincer form is actually the socket that can actually have an overgrowth of bone. And like you said, there could be both presenting, but no matter what, if there's an overgrowth of bone, sometimes they can lay, if you move the ball and socket joint around, it can lead to some unnecessary impingement. So the two, if there's an overgrowth of bone, those two can like kind of pinch together. But whether that pinch actually causes pain or not is a different discussion entirely. Would I say that correctly? Would you want to add anything in with that? Yes, that's correct. And then the other thing we could discuss, so then the labrum. So the labrum is a ring of cartilage that follows the outside rim of the hip socket. You can kind of think of it, if people are familiar, to like the meniscus of the knee. So the labrum of the hip, the role is to provide cushioning to the joint. And it kind of acts like a rubber seal, like you just said, holding that femoral head securely in the socket. And as far as like a labral tear, I think that, yes, people with any sort of hip impingement a labotae or a laboframe if a certain part of the labrum there's too much pressure on that part when the person is moving around and loading the hip. But yes, so you can have these things, but then it may not be causing your pain. So I think that. especially for runners where, you know, with running, we're not getting the hip into extreme ranges of motion. Like, the act of running itself is not causing positions of hip impingement. So, you know, I think that when you have pain and you have these findings, you have to really identify, like, what are the muscular weaknesses that the person has. I know that was certainly the case for me, that it actually came down to I needed to really strengthen my hip and make some changes to my training and that made my hip feel better even though I still have the hip impingement, I still have the labral tear, but it's just no longer a limiting factor. Would, so would you say that, um, the likely causes within the running population, would you say that there is maybe a strength deficit or is there something to do with someone's running or their particular, um, the terrain that they're on or the type of running that they enjoy doing, are there any particular causes that might lead to this condition? Yeah. So I think with With runners who end up getting this condition or end up getting hip pain and they have imaging and they find out that they have these findings, I think though, and the research is actually supporting this, that actually these changes in the hip, particularly the camrophology, actually is developing earlier on during adolescence and when the growth plate is open. And so, this becomes the big question is, so then these changes are occurring during adolescence and during puberty. And just like me, then the person can go on to complete high level sports and athletics, even throughout college. Then it's kind of like, well, what's changing, you know, in our 20s and 30s that then is causing these tips to become painful. And so I think that really what it comes down to is, that it actually has more to do with training habits and kind of the loading you're placing on the hip. And I think that that's one reason why I think most people with FAI and labial tears who want to get back to running can, once they have a training routine that is really sustainable and they're not. overtraining or undertraining. Yeah, I think, uh, like long story short, I think it actually comes down to more of the training factors that play a role in this than the actual, you know, bony changes of the hips. Because like you said, there, there may be 70% of the population that do have this particular bone overgrowth or some sort of impingement that just lays dormant lays asymptomatic people continue exercising and not even know that they have this but it's only until these training errors occur where the structure has said that's it I've had enough that's too much let me start producing pain in order to let you know that we've overdone things and if anyone's listening they're probably thinking this is the same. advice, the same education that's similar to any other running related injury. But I think it's important to know because there are some, I guess, misconceptions out there around FAI and labral tears. And it can be quite fearful, quite stark. If you get a scan because you have hit pain, they reveal, Oh, you have bony overgrowth. It's impinging on this and it's causing this labrum to tear. It can be very fearful and cause a lot of really startling language, particularly in the scan findings. But aside from that at the moment, because we know that it's so prevalent in the asymptomatic population, we do know that hip pain in general is a little bit more common in runners. And so if someone does start developing hip pain, it doesn't get better and they end up having an MRI, and it may potentially be an incidental finding that someone says, oh, look, you have this femoral acetabular impingement, maybe that's the sign of your pain, maybe that's the cause of your pain, I think it might actually be helpful in this particular part of the conversation to talk about what the symptoms actually are so that we can correlate symptoms with the actual pathology rather than someone falsely identifying the cause of their pain as this FAI. Right, right. So and I think it's also important to note that sometimes the symptoms of FAI, labral tear can also present similar to a stress fracture of the hip. So the first thing is making sure if the person has deep growing pain, sharp growing pain, and it's getting worse, it's causing altered mechanics, so they may be limping or after you run, you're in worse pain. I think the first thing is you want to... rule out any kind of a bone stress injury because it's actually common in people that have a stress factor that their hip also has underlying hip impingement and labral tear. So I think just right away kind of making sure that there's nothing serious or like what we call in the physio world like a red flag type of bone stress injury happening. And symptoms more related to hip impingement. So somebody may have deep groin pain. Their pain may be worse in sitting or like repeated flexion, so exercises that involve bringing the knee up towards the chest, flexing the hip. And then, you know, this is a physio term that we use. But oftentimes people will kind of make this C sign when you say like, hey, where does your hip hurt? So it's where they take their thumb and fingers and kind of make this C shape around the outside of the hip. And the symptoms of labral tear and the bony hip impingement often overlap. And like we said, so it's common for people to have both. And truly like... Still, the gold standard actually to identifying these changes is actually like a hip arthroscopy. So, you know, when they are like open up the hip joint and are actually looking at it. So that's another reason why we just have to be cautious with interpreting the findings of imaging. Because, again, you know, there can be things on imaging that, you know, we can't do it may not actually be the case when, you know, they're in there actually looking at the hip joint. A few things to really repeat there is you said it's very common for it to be deep and very common to be sharp groin pain. So deep, sharp groin pain. And when I talk with a lot of runners who think they have this particular condition, like a lot of times they point to say they rub along the outside of the hip, they rub like along their glutes or they rub along Um, their ITB or something and it's quite superficial. It feels like the symptoms are closer to the skin, which might indicate something else. Um, but that's particularly what you're saying. Like it's very, very common in this condition for it to be deep, it for it to feel like it's very hard to locate because it's so deep. And yet it'd be quite a shot, a sharp groin pain, which is increased with things like sitting and increased with things like, um, high levels of like driving a knee towards your chest, those sorts of things. Right. Okay. And, um, like you said before, it's can be brought on by training habits, like an increase, like doing an abrupt change, doing too much too soon. Um, and is there anything else in regards to what might cause this outside of running? Because I do know that, like say triathletes might listen to this episode or... you know, people have life outside of running. Is there any other conditions outside of running that might lead to this, um, pathology becoming symptomatic? Well, I think one thing that does make this a tricky condition is I think that it's, it's very multifactorial. So I think it's hard to kind of narrow it down, you know, as there's a specific thing that causes it to become painful, which again, also makes it hard for. Um... I think hard to treat it because you really have to, from the clinician aspect, clinicians really have to individualize the treatment for the person that they're working with. Because you're right, even if you look at different sports, so when I'm helping somebody with this condition and I'm treating a runner, there may be different considerations if I'm treating a hockey player. just based on the demands that the sport requires or the positions that the hip has to get into. So I think that for triathletes, I think, an important thing to note may be the position on the bike. So yes, the arrow position can be a pain provoking position if the hip is in a lot of flexion. And... I think that's probably the biggest thing to consider when looking at a triathlete versus a runner would be the biking position. But there are a lot of things you can do to work through that. It's actually funny. Because of my hip, that's how I got into also doing triathlons and was adding in the swimming and biking that really helped keep my training more well-rounded. And I think for the biking, it took several months, but I was able to make modifications so that my hip actually doesn't bother me when I'm biking. So I think it just kind of depends on really looking at what other sports or activities or hobbies or even things related to someone's job and what positions does the hip need to get in and seeing how can you. modify or change those while the hip is in a really painful state to make it feel better. Makes sense because if you look at the action of a runner, they don't really go through a lot of hip range of movement. They extend their hip and they don't really flex their hip too far. Maybe if they're doing heels or doing sprints, maybe, but in regards to like impinging on the bones, it requires quite a large range to do that. But then you talk about a triathlete or you talk about a cyclist or someone who's spending potentially some time in that aero position. That's extreme ranges of hip flexion. And if, if a training habit or a training era exists within that, I guess, aero position, then if they were an asymptomatic FAI population that might start becoming painful if it's, if it's overdone. But like you say, it's a fine balance because maybe doing triathlons actually helps distribute the load with different disciplines throughout the week. So you're not just overloading the hip in one particular discipline. You're actually, you know, offering different ranges, different strengths, different levels of fitness with different hip demands. So maybe that. distribution throughout the week is actually helpful for the condition. Right, right. And I think the other concept that I'll use a lot for people is just kind of looking at like risk versus reward. So in the, the sense of like the triathlete who wants to get in that, you know, intense arrow position, um, it may be a tough thing to think about, but in terms of looking at like, what's going to ultimately in the long run, be best for your hip. I think unless you're a professional triathlete and this is your job, but for people like me where it's a hobby, I think looking at the reward of being in that aero position and maximizing performance and speed, is that worth the risk of having your hip hurt worse or increasing your hip pain? So it's kind of how I approach things. me with my bike, so I actually have a road bike, a specialized road bike, and then I have aero bars on the road bike, and just that setup has kind of been optimal for my hip. So I guess I am sacrificing some speed on the bike, but to me it's worth it because I can complete hours of biking and not have any hip pain or pinching. Makes sense, yeah. So you're just making those modifications in order to reduce the likelihood of overload in a particular repetition. If you've seen a lot of this, if you've worked with this population quite a lot and you've done the research and you're familiar with the literature, are there any common misconceptions particularly with this condition, maybe around how it's diagnosed or the rehab or like treatment mistakes that people might, like you might commonly commonly come across? Yes, so I think that... I think that one of the things in terms of the diagnosis, I think when it's presented to someone as like, oh, your hip is hurting because you have the cerebral tear and you have the hip impingement, I think that's tough because sometimes the person will kind of get that in their mind that that's why they're having pain. But really, then once they have a consult with a... physical therapist and we do our exam which includes looking at their strength, their movement coordination, looking at the, like you said, correlation between their symptoms and how they're moving. Oftentimes, you know, we identify things that have to do with their strength, their movement coordination, and their movement patterns. And, you know, there's kind of this phrase that I use a lot when I'm... teaching our clinicians in our residency is that you want to like diagnose from the outside in meaning like rule out a red flag bone stress injury but then actually like treat the hip from the outside in or diagnose from the inside out, treat from the outside in. So meaning like, you know, oftentimes when you start strengthening the muscles and... loading the hip tendons, you can see a dramatic decrease in their pain. So I think, you know, one thing to be aware of is just, you know, not jumping to the conclusion that it's just the labroterine hip impingement causing the pain. And then in terms of treatment, so I think, I think now that there's more research out there, I'm seeing it less often, but I think, you know, like five years ago, it was really common that a lot of people with anti-hip pain were over-stretching the front of the hip and kind of getting that result where like it felt good in the short term, but then, you know, long term was actually making it worse. And so I think, you know, just identifying that your physical therapist, like that's what we do. So, you know, going to see a physical therapist and really having it. it assesses, you know, is it a true muscle tightness issue or often what I find is people will have hypertonicity, so that's where the muscle is really guarded and feels tight, but there's actually not a true muscle length deficit. So I think just being aware, you know, not over-stretching the hip. And then the other thing is, I think... that hips with FAI and labletors can benefit from manual joint hip mobilizations. But the clinician needs to recognize that oftentimes for these people, the aim is not to increase range of motion, right, because they're going to have bony limitations. But you can get what we call neurophysiological effects, so helping decrease the fear of bringing hip into different positions. And so in that sense, the manual therapy can help decrease the pain. I just think that clinicians also have to explain it in a way where, you know, they're not telling people like I'm mobilizing your hip because I'm gonna significantly improve your hip rotation. One thing I wanted to talk on when I was listening to your, like you on a previous podcast and you were talking about FAI and the presentation, the diagnosis, the misconceptions that are out there. I kind of drew a correlation with osteoarthritis and say osteoarthritis of the knee and someone, if we just take a runner, they overdo the, overdo, they do too much too soon, they've ran too fast or too. much of an abrupt change and they get knee pain and then they get scans and there shows mild to moderate osteoarthritis and they direct this as the cause of their pain. And so they've often told, hopefully less likely these days, but told that it's a wear and tear issue that it's gonna eventually wear out if you continue to, if you continue along this trend, there's going to be more and more breakdown of the cartilage and then you're eventually going to need a replacement. And it's a very, they draw a very clear line. It's almost like it's like a car where it has limited mileage. It has a finite amount of kilometers before the parts start wearing down and the parts need to be replaced. When in fact, what we know now with osteoarthritis is that, you know, exercise is very, very good for development of cartilage preserving the strength and preserving the, um, of, uh, actually preventing, uh, worsening osteoarthritis down the track. And we'll talk like, I heard you talk about FAI and people overdo things in there or they have some sort of training error, they then have hip pain. They then get scans and the scans show, okay, you have this bony overgrowth, which is the cause of your pain. And it's a very, um, It's very hard for people to wrap their mind around the cause of being a training overload because it is this bony overgrowth. It's something there structurally that can be very, very hard to go away or very hard to manage in their eyes unless they have surgery, unless they shave away this bone and allow range of movement and can be this very mechanical focused rather than the other side, which is more of like a strength and load management sort of focus. Do you see that much these days or is that just a, an arcade kind of old term solution that people have gone to? No, I mean, I think, um, I think that I, I still do see that. So I think, you know, you're, you're in Australia where, uh, anyone who knows me knows I'm such a huge fan of Australia because you guys have such great hip researchers there, everybody involved in the you know, out of La Trobe and Queensland and, you know, especially Jo Kemp. She's one of my, you know, idols, I would say, because of the great work she's done with FAI and LabelTairs. And so I think, I do think that it is kind of, the approach is different, you know, maybe in Australia versus here, because I do see here a lot in the US where... people do have the imaging findings and are often told they need surgery. And, you know, that actually happened to me. And like I said, this is when I was more of a younger clinician and didn't know as much as I know now, but I was also told that by a surgeon, like you have this labral tear, you need the surgery, you need to stop running, you're gonna get hip arthritis, which could lead to a hip replacement. And that did send me down this deep spiral of depression because it was kind of like one minute I'm able to run and the next one I'm being told that one of my favorite things in the world I can no longer do. But now, having gone through that and kind of fighting out of that darkness and Realizing that I could get back to running without surgery, without causing further damage of my hip, I have a lot to reflect on. So I think the thing with that is that, you know, people should be aware that there is still a lot more that's needed to be studied when it comes to the hip. So basically, you know, like... I think that when it comes to osteoarthritis, to my knowledge, you know, the way that I've heard about it from some of the leading, you know, researchers in the world and also in Australia is that actually the biggest indicator is kind of your genetics. You know, some people just have a genetic predisposition that they have a higher chance of ending up with osteoarthritis. And so it also depends on, too, the... how big the hip impingement is. And that kind of gets into the nitty gritty of the imaging and the radiology aspect of it. But I'd like to think of it as a spectrum. So there's people that have, say for example, a hockey goalie that has severe hip impingement, camlithology for their position, maybe their job as their professional athlete. They have to be able to get into repeated extreme ranges of motion. So they may be somebody who may need the surgery, may benefit from the surgery, to allow them to do their job, which is to play the sport. And then there's people like me where, my imaging findings didn't show that I had a significant camerthology. And so it's still unknown if hips like mine will end up to go on to get hip osteoarthritis. So, I think that there's still a lot that we have to know about, you know, who's going to get worse. I think one thing that, you know, is known is that if you have cartilage defects, also with labial turn FAI, yes, your hip is at risk of getting osteoarthritis. more so than somebody who has labral tear and FAI but doesn't have a cartilage defect. So, that can be a helpful thing to consider when looking at long-term management. And actually, you know, Jo had said this in one of her presentations, like for, in that scenario when you have a hip with a labral tear or FAI and a cartilage or chondral defect. you should actually kind of treat it as if they already have like earlier way, meaning emphasize keeping active, keeping the hip mobile, sustainable training, that sort of thing. 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Um, uh, I'm curious when you were told that when you had the scans and you had a surgeon saying you might need surgery and you might need to give up on the sports that you love, and you said that you found yourself in a deep depression. When did that turn around? When did you find out that maybe surgery isn't the option? You can actually treat this with, um, exercise strengthening and just load management. Yeah, so I would say for a period of probably like five to six months, I actually did stop running. And this was right when I was also in a physical therapy residency in orthopedics in Baltimore. So I was at the Johns Hopkins Hospital. And so it was a pivotal point in my career, you know, with the intensity of the residency program. And so I had stopped running for about six months and I was just, I actually was planning to have the surgery that summer. You know, I was kind of still in that mindset of like, I have this problem with my hip and it needs to be fixed. And so that was kind of my mindset was just get through the year and I was going to have the surgery. But then I think, you know, things started to change when I got like a second opinion and they offered it. like a different surgery, you know, like they had mentioned adding in a micro fracture, which is a really intense and tough recovery for the hip. And so that's kind of when I started thinking, huh, maybe surgery is not the answer for me. And luckily, one of my mentors who is a well-known physical therapist in terms you know, treating people with persistent pain and looking at the psychological aspects like stepped in, his name is Mark Shepherd. And he was really that clinician that, you know, was able to change my perspective about my hip, you know, and he said, let me evaluate your hip, let's do formal physical therapy. And after that, and he noticed all of the things that could be. such as my, you know, increasing the strength of my hip, increasing the single leg control, and working on more well-rounded training, so adding in more strength training, more biking and swimming. And he really helped me get back to running. You know, and I remember him asking me, like, what's holding you back from running? Why aren't you running? And my answer, I mean, I was really, like, catastrophizing at that point, but was because I was so afraid that... I was going to make this worse. I was afraid I was going to damage it. And he said, well, if even the top researchers don't yet know if that's the case. And now, years later, like you're saying, we know that actually running an activity is helpful for these kinds of hips. He really challenged me to be my own experiment. that belief in me really helped. It really changed my thoughts about my hip and it was a very gradual and methodical progression back to running that involved, you know, I think it takes a team to help these people and I'm really grateful that I had a great group of people on my team, which included, you know, the physical therapist. I then worked with a strength and conditioning coach. I also worked with a sports psychologist. who really helped me with the fears about my hip and kind of the uncertainty. And then getting back to running, I worked with performance coaches, Chris Johnson, Nathan Carlson, and Joel Sakgas. glad that you had so many resources and so many people on your rehab team to help you through that because I could easily see a recreational runner have the same start as you and the same pain, the same scans, the same like initial suggestions to just go through that path without, like you say, being your own experiment, trying other things and seeking out second opinions and having that, that rehab team. So I'm glad you've kind of had that insight and you've seen the um, the benefits of it. I want to get through to some, um, questions that came in. One was from Chitra and she asks, um, can a hip impingement and label fraying, so she had an MRI that diagnosed label impingement and, uh, label fraying and a hip impingement. Um, and then she later developed proximal hamstring tendinopathy. So she was asking, can this condition cause other issues such as PhD? Yes, so I do think that someone can have proximal hamstring tendinopathy. I think that happens when you have weakness of the hip. So, you know, weakness of the flexors, adductors, the gluteals, and then the hamstring is really having to do a lot of the work for the hip. And then over time, that can lead to irritation of that proximal tendon and then which can then... causes inhibition leading to hamstring weakness. So I think that is something that can happen. I think it has to do with the hips starting to compensate and which in terms of treatment is another reason why it's really important for these people that you're exercising all the muscles of the hip, adductors, flexors, gluteals, hamstrings, deep rotators. And that's a good. good advice for PhD clients anyway is to strengthen the hamstring but also strengthen the muscles around the hip can be really important. So like you say, you kind of treat outwards in and so you start with all the tendons, the muscles and building up all that control and then you know, working your way more inwards. Thanks for that answer. Charlie also asks, what is the risk of making it worse? Like if, if running does cause a pain is there much threat or is it ill advised to continue running through the pain? If so, is it causing more damage? That's a good question. So I think that it kind of comes down to, you know, soreness rules that we utilize with other injuries as well. So I think before someone, let's say, for example, someone gets diagnosed with FAI labial terror, they have hip pain, and they are trying to decide, can they hold off on running or? Can they keep running? So I think that the first thing is if you have altered mechanics with just walking, you know, you need to dial back. The other thing is needing to kind of really be able to tolerate walking. So I'll have people, you know, I'll tell them, can you tolerate 45 minutes to an hour of fast-paced fitness walking? Because that's really a prerequisite to being able to. tolerate the loads of running on the hip. And so I think if you utilize those soreness rules where you're paying attention to altered mechanics, the other thing is 24 hours later, the pain should be back to baseline. And then if it's not, I think that's a sign you need to dial back. So I think the hard part about this condition and getting back to running is that it's you have to continually kind of reassess how you're doing. So which I think is hard because people often want to just get that green light to go run. But this is a condition where if you don't gradually progress your mileage and your pace, and you just go out and do back to back long runs and really fast runs. too soon, you can kind of get stuck in this cycle of flaring up the hips. Is there, uh, so what you're saying is there's no, it's more of like symptom dependent, um, flare ups rather than they're running a risk of structurally any increase in damage taking place. Right. I think, I think that people have to be aware of those that, you know, the, the weaker your hip is, there is going to be more stress placed on the joint and the bones. So. keeping that in mind, but I think if you have somebody who has really like put in the work and their hip is strong, that in the approach training in a sensible way that you are not going to make it worse. Um, it's funny, like I think the, the listeners of this podcast, especially if they've listened to other episodes in the past, like you're getting all these expert therapists on to discuss all these different conditions and the advice is the exact same for every single condition. It's focusing on load management. It's paying attention to symptoms. It's making sure that if it is elevated level of symptoms during exercise, we want to make sure that it's low levels of. soreness and that it's settled down within 24 hours. Like that's like load management 101 for a lot of running related injuries. And, um, it's sometimes encouraging to know, sometimes encouraging to have different guests on and have this exact same advice come back because that kind of solidifies our, our thoughts and our understandings of these conditions. Sometimes that repetition is really needed. Um, so I'm glad I'm really happy that we're like. this FAI label tears, they fit within the same umbrella of load management and those particular management skills. Right, right. I'm almost 100% convinced that I have like an asymptomatic FAI because I remember doing tests when I was a physio studying. we did that same, like you lie on your back, you bring your knee up to 90 degrees and you rotate the hip and you have someone rotate the hip. My right side, it just locks up straight away without, it's just like a hard feel, just won't go anywhere, just locks up immediately. And I do feel a little bit of like deep hip soreness when people do that. And like to say last week, I had this gym installed in my house and I was doing like. Installing treadmills and gym equipment. It was a lot of deep squatting, unloading boxes, putting together like Alan keys and screws and just like attaching, um, all these different parts and like a day of like deep squatting, my hip had this like deep hip soreness for a couple of days, it quickly settled. So I'm almost convinced that I have FAI and in most cases throughout my running throughout the week, it's just asymptomatic, just lays completely dormant. So I may, I may be a part of that 70%. If this. Yeah, I mean to give you also perspective like my story is actually not that unique when you start to hear of other people with FAI and label tears, you know, and two of my best friends, you know, like a couple years after I went through this, two of my best friends who are also marathon runners got diagnosed with the exact same thing, you know, so it's kind of like the more people you talk to, it seems like it's the more people you're going to meet that also have FAI in a labral tear. So join the club. It's a nice club, but it seems to be a majority. Like if you say that the incidental findings or like these scans, asymptomatic populations around 70%, that's, that's the majority of the population out there. And so you, if I do know some runners who are injured, they're quick to go get scans for some reason, it seems to be their first point of call is to get an MRI. you know, to see what's going on. Cause they think very mechanically to see if there's anything structurally going on. And so the likelihood of them coming back with an FAI diagnosis is extremely high. And so, um, I say this in most cases, you, you do want to correlate symptoms with findings as well. And even if those findings do come back with FAI, FAI or osteoarthritis or something, make sure that, you know, surgery isn't the straightaway first option. you wanna make sure that you treat it conservatively to start with, especially if it's like the first time you've had it, particularly if it's presented with this training error, because all it just might take is some load modification and some strengthening, and then you never see it again. Maybe. But like you said, there can be some situations where it just doesn't go away, you treat it conservatively and it just doesn't settle, and you're also... more likely to like your livelihood relies on a deep squat rotation. Like you say, that hockey goalie example, um, where surgery might be that option for you, but we do need to be very careful and be very well educated on this particular, um, condition and all the options that you have available before seeking out or choosing that, um, surgical path. Right. Is there any other, um, things that we haven't discussed? Is there any other advice around management? Any other advice around treatment that we haven't discussed already? I think perhaps kind of delving into like the time, you know, it takes to kind of treat this condition. Cause I think that that's something too, that makes it a little bit tougher than say, you know, other kinds of injuries. Although I guess you could say it's similar to tendinopathy in that it takes months. So something I think that they have studied too that, you know, in looking at people who went on to have surgery, looking at the outcomes, that it actually had, their outcome had nothing to do with, you know, the size of the labral tear. It actually had to do with their expectations of how long it was going to take to recover. So what that means is that, you know, as clinicians... educating patients that this is going to take, you know, six months to maybe a year, maybe even longer for them to really get, you know, close to 90%, 100% better. And even then, I hesitate to say 100% because, you know, even if you have surgery or you don't have surgery, like zero out of 10 pain 100% of the time is really never the goal. So I just think that, you know, kind of being cautious with what your expectations are in terms of how long it's going to take. So for runners listening where like maybe they're thinking, okay, I was told, you know, six weeks of physical therapy and this should be better. But the reality is you're actually looking more at like six months of physical therapy. And the reason is because like we said, it's not going to be a good result. it's so multifactorial and there's so many training and voting considerations you have to look at. So I think just kind of emphasizing that, that it takes a while to get better, but it's worth it to kind of stick to the path and not search for any like quick fixes that sound really appealing. Again, it comes back to education, I think just being well informed and recovery timeframes and expectations are just a part of that education piece, just making sure you have, you make that informed decision, making sure that you truly understand what it takes throughout that recovery process. And I like how you talk about the, the zero pain being kind of unrealistic. I talk about that in a lot of chronic tendon issues, like People say, how long until I'm running pain free? And I say, well, you could go back to running six marathons a year and still have a one out of 10 pain every now and then. That is extremely successful. That is like getting you back to everything that you love doing, but there's still like some symptoms lying around here and there. Setting that expectation and set like if you, if symptoms remain really, really low. And stay low, not zero, but stay low, but your load increases and you go get back to competing in races or you get back to running a certain mileage or a certain speed, then that's counted as a success throughout the recovery. Um, so very good to lay down those expectations and have that education. What, would you agree with what, what I was saying about the load, um, load increasing symptoms staying the same or do you, do you change your education at all? No, no, I agree. I agree. And I think, uh, Yeah, and I think one other thing for people to realize too is that it is a tough thing to go through. I think there was some statistic that Mike Raymond, who's a PT out of Duke who did his PhD on FAI, he would always say that the average person sees three to four healthcare providers before kind of actually finding out what is causing their hip pain. for the runners listening to the podcast, I think just recognizing like it can be, it can take a toll on your mental health. And so don't underestimate, you know, the power that working with a psychologist or sports psychologist can have on the recovery. I think that's something that really helped me. And I think it's something I often recommend to a lot of my patients because I think it's a crucial part of recovery. And you have been gracious enough to leave me some social media links before the interview. So I have your Instagram, plus PT performance, as well as the website under the same name. And anything else? So I see your email here. Do you want me to include that in the show notes as well? Sure. Yeah. That would be great. I'm sure if anyone has any questions about FAI or label tears after listening to this episode, they'll be happy to, if they do have any. Other questions or comments or queries, then I'll definitely leave your, your email in the show notes. Uh, any other final takeaways before we wrap up this episode? No, I think, uh, I think it was, I think it's going to be really helpful for people listening. I think it was a great discussion and thanks for having me on the podcast. And, um, yeah, if anybody has any questions or comments or needs guidance with their hips, please don't hesitate to reach out. And that concludes another Run Smarter lesson. I hope you walk away from this episode feeling empowered and proud to be a Run Smarter scholar. Because when I think of runners like you who are listening, I think of runners who recognize the power of knowledge, who don't just learn but implement these lessons, who are done with repeating the same injury cycle over and over again, who want to take an educated, active role in their rehab, who are looking for evidence-based long-term solutions, and not accept problematic quick fixes. And last but not least, who serve a cause bigger than themselves and pass on the right information to other runners who need it. I look forward to bringing you another episode and helping you on your run smarter path.