Saturday, June 14, 2014

FAI: A Beginner's Guide to Being Overly Hip

From now on, you can just call me Lady Gaga.

No, not because I'm a bottle blonde with a sometimes unorthodox fashion sense who at one point in my childhood owned an electric keyboard.  I recently learned that my kindredness with Ms. Germanotta goes much deeper than that - as deep as our hip joints, to be precise.  We both have a joint condition called femoroacetabular impingement (FAI or hip impingement, for short).

FAI occurs when the ball-and-socket hip joint is abnormally formed, usually during the fast-growing years of adolescence.  Ball-and socket joints normally fit together like a clenched fist into a curved palm (think paper-covers-rock style - which I think we can all agree is the outright lamest of the three paths to victory).  FAI occurs when either the "rock" develops into a funny, bumpy shape rather than round and smooth ("cam impingement") or the "paper" juts out too far over the rock ("pincer impingement" - like the awkward, clammy hand of your teenaged big brother who somehow always figured out a way to beat you at this supposedly chance-based game).

If you believe you may be suffering from rainbow-colored-socket syndrome, please hang up the phone and dial 911.

Typically, a thin layer of cartilage and fluid inhabits the small space between the head of the "rock," or the thigh bone (also lovingly referred to as the femur) and the "paper," or the round concave part of the pelvis (the acetabulum).  When the head of the femur fits snugly and correctly into the acetabulum, there is less friction within the hip joint than one-tenth of that felt while gliding on ice.  (Whether this analysis was done after two hours of family free skate or on a freshly Zamboni'd rink was not mentioned.)

The Signs and Symptoms of FAI: Is that a pulled muscle in your groin, or are you just happy to see your physical therapist?

FAI seems to be all the rage these days, with everyone from our favorite Poker-Face'd pop star to a handful of sports-legends-whose-names-I'll never-remember retrieving a diagnosis.  But for many years, FAI was commonly misdiagnosed as a muscular injury, due to the hard-to-describe and often-changing nature of the pain it brings.  Most patients report a deep, aching pain in their groin area that increases with long periods of physical activity or sitting, so this is usually described as classic FAI-related pain.  But because the pain comes from the very middle of the upper-hip area, and can affect any part of the hip joint in particular, the pain may also be more intense in the front and side (anterolateral region) of the hip.  Many patients describe this pain to their doctor by cupping their hand into a C-shape and placing it on the hip to indicate the range of pain, like this:

"My hips, or in this case the 'C-sign,' don't lie."

I personally have never felt any groin pain along this journey, making the several weeks in which I attempted to self-diagnose using my WebMD degree from Google University a complete failure.  What I did feel was a dull pain after sitting, while running or walking, when standing on one leg, when jumping on one leg (oh, Lord, did I feel it when jumping on one leg), and when raising my knee.  And the famed "C-shape" just so happens to be the exact sign I showed to my doctor, and then to my physical therapist after two straight months of dull aching punctuated by the occasional sharp shock of pain jutting from my hip bone and half-way down my thigh.  But they don't tell you this at Google University.  (This pain also made for two straight months of crabby complaining and tears of hypochondriasis mixed with frustration.  Thanks for putting up with me - you know who you are).

For some unlucky folks, mysterious lower-back pain on the side of the affected hip as well as sciatic pain may also occur, making the diagnosis even more confusing.

Further complicating the differential diagnosis for FAI is the fact that the results of an x-ray, if ordered by a concerned but stumped doctor, will be labeled "normal."  "Normal" is radiologist speak for "no scary cracks or crevasses in your bones that we know of," but it doesn't mean your joint is necessarily shaped the way it should be.  One possible clue: my x-ray results suggested "minor calcification of the femoral acetabular area," meaning that the grinding bone-on-bone action (I see you in the back, snickering) had already caused some disturbance to the joint.  If that motion continues, I can look forward to an early-onset case of arthritis and possibly a bionic hip later in life.  Well, that's a bummer.

Who gets FAI?

Here's what makes FAI a complete bugger of a diagnosis.  Anyone can have FAI - all it takes is to unwittingly develop some wonky-shaped hip bones.  But FAI only starts to hurt when the bones have come into contact with each other due to constant, full-range motion.  Once any pain is felt, that means a certain amount of damage to the hip joint has already occurred.

The condition is usually asymptomatic (and therefore benign) unless you are an active individual who loves to get outside and breathe the fresh air, break a glistening sweat or feel the stuff of life pumping through your veins - be it in running shoes, a kayak, baseball cleats, or hockey skates.  That's right.  The stuff that puts zest into your life, that you anxiously await the weekend for, that makes life an adventure worth taking and a game worth playing...  is also causing you considerable, restricting pain that may give you arthritis way before all your friends get it.  And maybe even a shiny new hip before you can afford that retirement hotrod.

Well, this wasn't my exact idea of a mid-life crisis purchase.

In other words, FAI is most likely to affect individuals who just really can't have that kind of negativity in their life - who will be stopped by physical pain from fulfilling their life-enhancing hobbies and passions.  The pain can be at worst unbearable and debilitating, and at best nagging and guilt-inducing because should I really be out here running in the sunshine/shredding some gnarly powder/swimming with dolphins right now because my hip hurts kinda bad.

Generally, the populations most affected by FAI are recreationally active women in their 20s, 30s, and 40s, and young-to-middle-aged male athletes.  Women are more likely to suffer from pincer ("paper") impingement, while men are more likely to be diagnosed with cam ("rock") impingement.

But don't go running for the Cherry Garcia just yet.  It's going to be ok (it better be).

Some stone fruit-flavored ice cream to take your mind off all the horrible things I just told you.

What can be done about FAI?

If you've only been dealing with pain for a few months to a year, a conservative course of anti-inflammatory meds and a round of physical therapy can be successful in alleviating symptoms and getting you back to doing the things you love.  Remember, this line of treatment cannot cure  FAI, but can reduce and prevent the pain and damage associated with it.  Physical therapy for FAI typically involves the use of targeted stretching techniques and devices that will help alleviate pressure in the joint and restore space between the femur and the acetabulum.  Special exercise routines can also help strengthen certain muscles that will help stabilize and protect the hip joint in the future, preventing further pain and damage as you eventually return full-force to your favorite activities.

Clamshell exercise using a resistance band, a common therapeutic technique for FAI.  Also, what Mickey Avalon was secretly writing about when he wrote about doing the Jane Fonda.

If ibuprofen and physical therapy don't appear to alleviate the symptoms of FAI, surgery may be considered.  For these forsaken athletes and active individuals who want to live free of pain and prevent joint damage, surgery can physically remove the bone overgrowth that is causing the impingement, as well as stimulate cartilage repair if needed.

Surgeries can be of the arthroscopic or open variety, the latter of which is usually only used in complex cases of FAI.  In arthroscopic surgery, a small hole is made near the hip, and a videocamera is inserted.  The surgeon then uses tiny tools to remove the offending bone material, using the video feed as a guide.  This procedure typically takes 1-2 hours and can be done as an outpatient.  In an open hip surgery, a larger, 7-10" incision is made on the side of the leg, and the joint is purposefully dislocated in order to remove bone material and repair damaged tissue.  A couple screws are then used to reattach the femur to the acetabulum.  This type of surgery takes a few hours to complete, and an overnight stay is usually recommended.  For either type of surgery, recovery time includes 3-4 weeks on crutches, 2-3 months of rehabilitation and strengthening, and another 3 months getting activity back to pre-pain levels.  Most patients report a full return to hop-, skip- and jumping after the 6-month mark.

Given that I became a blubbering bag of nerves and saline when I saw the IV needle before the teenage rite of passage called getting my wisdom teeth pulled, it's safe to say that I will be doing everything in my power to treat my hip pain surgery-free.  Needles are not welcome for an extended stay in the temple that is my body.  Rather, lots of stretching, traction devices resembling new-age torture machines, and the rubbery stench of Thera-bands are in my near future.  A slow and patient return to full activity is in my long-term plan.  But while I can't see myself going into a surgery without tearing through two boxes of Puffs, a few brown paper bags, and maybe a bottle of Xanax, it's even less likely that I will allow my condition to keep me from doing the things I love forever, including running with abandon - not gingerly limping - through the rain.  I've crossed my fingers that it won't have to come to that decision.

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