Hip Impingement (FAI) & Labral Tears: Is Rehabilitation Truly the Best Route?

Phil Plisky, PT, DPT, ATC, CSCS

I want to discuss some practical insights from a recent episode of the Rehab & Performance Lab where we tackled hip impingement, hip labral tears, and the burning question: Is rehabilitation truly the best route, or is surgery the answer? I was honored to be joined by Dr. Benedict Nwachukwu, an Associate Professor of Medicine at Cornell Medical School and an orthopedic surgeon at the Hospital for Special Surgery, who shed some light on these issues. 

Three Big Insights from the Rehab and Performance Lab

We kicked off our discussion with some really critical insights that may change how you think about hip health, especially as it relates to other common injuries like ACL tears. Here's what we covered:

1. Steroid Injections: A Hidden Risk for Poor Outcomes?

It's true, and it might surprise you! We learned that steroid injections, especially multiple ones in the hip, can actually decrease the healing rate of hip labral repairs and any bony work done during hip arthroscopy. This challenges some old lore, but the research is showing us that steroids can really impact the ability of tissue to heal across multiple joints – hip, shoulder, knee. So, if you're looking at potential surgery down the line, this is a huge factor to consider for long-term success.

2. The Hip as a Three-Layered System: Bone, Cartilage, and Muscle

Dr. Nwachukwu has a brilliant way of viewing the hip: as a three-layered system. Think of it as the bony layer (where impingement issues like CAM or pincer deformities happen), the cartilage layer (including the labrum, which is often an "innocent bystander" to bone issues but can cause a lot of pain), and finally, the muscular layer.

This is so critical because Dr. Nwachukwu emphasized that he addresses the muscular layer first. Why? Because strengthening those muscles around the hip – especially the glutes – can actually compensate for bony and cartilage deficiencies. It's about taking stress off the labrum and even gaining range of motion through muscular stretching. And guess what? This layered approach also informs post-operative rehabilitation, making sure we restore the timing those muscles after surgery. It's a systematic way to think about the body. I use the Selective Functional Movement Assessment to sytematically identify the problem area.

3. Your Hip Impingement Might Be Why You Tore Your ACL

This one is a big deal, and it's a message I'm always preaching: you have to look at the entire body systematically. We discussed compelling research that showed a direct link between hip impingement (specifically, decreased hip internal rotation) and ACL tears, especially in high-level athletes like those entering the NFL. Players with reduced hip internal rotation had a six times increased risk of tearing their ACL!

And if you've already torn your ACL, you're likely to have decreased hip internal rotation too. This isn't just about the knee; it's about how the entire system functions. If your hip isn't moving well, you're putting increased stress and torque on your knee and ACL, particularly during jumping and landing. We know this, but how are we systematically addressing it. It reminds me that unless we're systematically approaching the whole body, you're just another statistic waiting to happen. We're a system, not just a joint, folks!

What Else Did We Discuss? 

Beyond these eye-opening connections, we dove deep into the nuances of hip preservation, for anyone dealing with hip pain or looking to optimize performance.

Conservative vs. Surgical: When Is Rehab Enough?

As a rehabilitation professional myself, my answer to everything is usually "everything but surgery". And it's fantastic to hear that Dr. Nwachukwu often tells patients to "go go go do PT; you're more likely than not never to need my services". The "FASHIoN Trial" study out of the UK showed that 60% of patients with hip impingement do well with physical therapy, typically with about three months dedicated to good PT.

But when should you consider surgery? We talked about important signs for early surgical consideration, like "chondrolabral delamination" on an MRI, which means the cartilage is at risk of detaching. For high-level athletes, if you're not seeing significant improvement after six weeks of dedicated PT, it might be time to consider an operative approach given the demands of the activity.

The Unsung Hero: Prehabilitation

Here's a concept I can't emphasize enough: prehabilitation is key. Even if you end up needing surgery, according to Dr. Nwachukwu, optimizing those muscular layers beforehand can significantly improve your post-surgical outcome. Patients who go into surgery with higher hip extension strength tend to get off crutches sooner and walk without a limp, expediting recovery. It just makes sense – you're giving yourself the best possible foundation for healing!

Setting Expectations and the Long Road to Recovery

Recovery from hip arthroscopy can be a long journey, so setting expectations through shared decision-making is critical. If we haven't set the goal line, the patient might move the goalpost, and no one's happy. Dr. Nwachukwu's four phases of post-operative rehabilitation for hip preservation are a great roadmap:

• Phase 1: Activation – Focusing on glute activation, passive range of motion, and soft tissue work.
• Phase 2: Muscle Strength – Around the two-month mark, building hip extension, abduction, and overall strength.
• Phase 3: Sport-Specific Activity – Starting around four months, introducing running, agility, and anti-gravity work.
• Phase 4: Targeted Sport Work – Simulating game activities and preparing for full return to sport, whether it's pro basketball or an Orange Theory class.

And remember the ACL similarity: the hip labrum's healing and proprioceptive ability can take months to fully mature, similar to an ACL. This is why sticking with a comprehensive rehab program for nine months or more isn't just a suggestion; it's about giving your body the time it needs to truly heal and rebuild that vital neuromuscular connection.

A Message to My Fellow Rehabilitation Professionals: Be Systematic!

If you're a rehab professional, here's what I want you to take away from this conversation:

• Communicate with Your Surgeons: Dr. Nwachukwu emphasized how much he appreciates objective information from therapists – identifying deficiencies, progress made, and plans. He wants you to feel empowered to reach out directly and collaborate. No one likes to be blindsided!
• Don't Forget Manual Therapy: Dr. Wanuku is a humongous fan of dedicated manual therapy. 
• Be Systematic in Your Examination: This is huge. Don't just do "exercise in general". If you're systematic in your examination, you can be incredibly efficient in what you need to address. Does a patient need more soft tissue work, or is strength the main issue? Precision in your examination allows you to spend time where it's truly needed, leading to better outcomes.

Ultimately, our goal is to listen to our patients, optimize programs for their specific goals, and continually force ourselves to learn something new every week. It's about being collaborative and recognizing that we're all part of the patient's path to mastery.

These aren't just theories; these are proven strategies to get your patients with hip issues and those at risk of ACL injury back to high-level performance and prevent long-term issues. If you want to dive even deeper into systematic strengthening and high-level performance, be sure to join us in the Coaches Club. Your Path of Mastery begins here.

You can listen to the full episode at the links below. If you'd like CEUs, make sure to use the MedBridge link.