FAI Hip Impingement (Femoro-acetabular Impingement)

FAI Hip Impingement Awareness facts - It is estimated that approximately 15% of the young, adult population have hip impingement, so who do you know that might have it?
Hip impingement causes painful labral tears within the hip socket.
Hip FAI symptoms are misleading to the average medical professional, as FAI hip impingement pain frequently presents as low back pain and interesting only 10% of back pain is ever clinically diagnosed and cured... Which begs the question what percentage is actually caused by hip FAI or hip impingement, as its otherwise known.
The more active you are, the more likely you are to trigger hip impingement symptoms, so busy mums and gym bunnies beware... but at least you're in good company as many premiere league football players have also suffered FAI hip pain.
Hip impingement is diagnosed through x-ray and labral tears are diagnosed through MRI arthograms - but both need to be read by hip consultants specifically trained in FAI hip impingement.
There are 60,000 hip replacements every year in the UK and it now appears that FAI hip impingement, over the years, could be the leading cause of hip osteoarthritis. A silent epidemic.
Hip arthroscopy can reduce the hip impingement and reattach the torn labrum to the hip socket. This surgery can eliminate the pain and disability caused by FAI hip impingement and divert the need for hip replacement in later life.


Also please feel welcome to join in our help and advice forum for support. We have 3 advising FAI expert hip surgeons, 3 PT/physios and a sports medicine doctor as well as the largest international FAI hip impingement forum on the net:

Wednesday, 11 June 2014

Hip Arthroscopy rehab - A psychological perspective, by guest writer Mandy Graham.

Hip Arthroscopy Rehab – The Psychological Perspective
Mandy Graham
BSc (Hons) OT; Msc OS
Hip Arthroscopy Patient 2014

My Story by Mandy Graham:
I’ve had ongoing back problems since age 18, but it didn’t cause any major problems – I still managed to run a half marathon aged 20! Occasional flare ups would generally get better with physio. 

The problems with my hip started in my late twenties – I would notice after certain activities e.g. gardening or decorating / DIY, that I would experience pain in my left buttock – but on waking the next morning it had gone. 

In 2010 aged 31, I had my first child. The pregnancy and 4st weight gain definitely exacerbated my hip problem but once she was born, it eased and although unfit, I was able to walk with the pram most days for 45mins to an hour and lost most of my baby weight. 
In 2012 I had my second daughter and gained 5st in weight! This time I was less active after the birth and I have still not lost all the baby weight! However my hip pain at this point was still only intermittent following activities that involved lots of bending.

I’m an Occupational Therapist and have specialised in mental health for the past 14 years. My jobs have gradually become more sedentary, as I moved into management roles. 

The real flare up for my hip came when I changed jobs in Sept 2013 and had a 50 mile round trip to work every day and then a 10 min walk from the car park. Looking after my 1yr old and a 3yr old also meant lots of bending and sudden movements. 

So, I went to see my GP, armed with a letter from my Physio and suspecting hip impingement.  The pain was getting difficult to cope with at this point and I was referred to Mr Conroy. 
After an x-ray and MRI arthrogram, I was diagnosed with FAI with labral tear in Dec 2013 – at this point I was on Ibruprofen every four hours during the day and 30mg codeine on a night for pain – plus tablets to prevent irritation of my stomach. 

The impact on my daily functioning and quality of life was quite severe at this point and definitely impacted on my mood. 
The most upsetting part was struggling to look after my young children and not being able to take them to the park, or to soft play centres by myself. Getting through the day at work after not sleeping well was also a major struggle.

I had surgery on 26th Feb 2014. Immediately after surgery came the massive relief that my hip pain had gone – I came off all pain meds 4 days post op and just used ice! 
The first 4-5wks I felt great – no or very little pain, doing all my exercises (very motivated!), resting, eating well (probably too well!), took it easy and didn’t feel guilty for being off work! What did surprise me was how tired I felt and I had to have lots of afternoon naps. However I felt content just being at home (we moved house the day after my operation!), enjoyed day time TV and the peace and quiet as my daughters were in nursery all day. 

6-10wks post-op was emotionally hard. I felt I should be better by now. I felt frustrated, less motivated to do my exercises and my mood dipped. I also still felt really tired and had put on nearly a stone in weight – which made me feel rubbish! 

At 10-12wks I started to look back at how far I had come and the realisation that this was no quick fix! So at 12wks post op, guided by my knowledge of being an OT, I wrote some hints and tips to maintain positive mental wellbeing during the rehab process. I hope you find them useful.


Hints and Tips for Patients
Disclaimer – the following hints and tips are intended solely as a generic guide from a patient perspective. You must follow the specific advice and rehab information given to you by your designated health care professionals.

Pre-surgery
Think about how you are going to spend your time post surgery. It Sounds simple but it’s really important. Our roles, routines and daily responsibilities all shape our personal identity, and these things change post surgery – not just for a few weeks but it may be months before you can return to activities and hobbies that make you who you are. Patients need to think about how this will make them feel. 

For me even though I was in pain for months before my operation I was still managing (all be it a daily struggle!) to work full time in a demanding job, be a mum, have a social life, and have a very busy routine. Suddenly all that changed. 
As OT’s we call this occupational disruption. At first it can be a novelty – time to watch movies, read books – great I hear you say! But after about 6wks it becomes more of a frustration and there’s an urge to do more but the body is not responding as it needs time to heal – and this can lead some people to feel low in mood. 
This is even more of a challenge to sports men and women who are used to being physically active.
Be open with your employer about how long you may be off work. Of course this depends on your job role, your entitlement to sick pay and exactly what surgery you’ve had done. 

Working in the NHS my colleagues all thought they knew about hips and thought I’d be back in 6wks max. 
When I hit the 6wk mark and still felt so drained and tired I was so relieved for my doctor to explain that often people need 12wks or more off work. 
It didn’t stop the feelings of guilt about being off though so it’s important to view this as your time for your rehab. 

My surgeon says a successful outcome is 50% surgery and 50% physio and rehab afterwards – so you must commit to this and make others aware of the importance of this time on your recovery.

Ensure you have adequate child care sorted out – You will need help to look after young children due to all the bending involved. 
Older children may be able to help you with tasks around the home but you will need quiet time too to rest and sleep. 

There may also be financial implications if you are paying extra nursery / child care fees. 

From an emotional perspective it can be very hard when you can’t pick your child up when they have fallen, or carry them when you are on crutches, or go to them when they wake in the night. 
Although it is hard try not to feel guilty about this – think about the longer term and hopefully that if you focus on rehab now you’ll be able to run around after them in the future!

Practice relaxation methods in the weeks BEFORE surgery – I’ll suggest some simple self help techniques in a moment, but it’s important that you are comfortable and familiar with these, so you can implement them easily post op. Relaxation also helps with pain management pre-op. 

Realistic goal setting - Think about what’s really important to you – what are your post op goals going to be? Discuss these with your surgeon and physio – they will help you understand if they are realistic or not! 

For me all I wanted was to be pain free – I could not mentally see past that point, which is why I think when I was pain free so soon after surgery (lucky me!) – and then off my crutches – it was like ok, so now what? What is realistic? – I simply didn’t know.


Post-Op
Focus on the here and now – I would often feel frustrated about how little I had accomplished during the day. My husband and daughters would leave the house at 6:30am and return at 6pm. My husband would ask (in a caring way) – “so what have you done today?” – Erm... I did one load of washing, put the dishwasher on, made a few phone calls / sent emails and had a nap! 11 hours would go by in a flash. 

I didn’t feel lonely being on my own, as it never felt that long, but having previously had a very busy work and home routine it did real strange just “being” rather than doing. 
However “being” and focusing on the here and now is very important especially as it can be difficult to plan for the future – such as days out, holidays – how far will I be able to walk in three months time? 
There are a lot of unknowns. 

For an athlete this can be even harder, thinking about when they will be able to return to training or competing. 
It may be useful to read up on “Mindfulness” which involves paying attention to the present moment, and can help people change the way they think, feel and act.

Adapting daily activities – Being independent in personal self care can be quite easily achieved post op with assistive equipment such as raised toilet seats, shower stools, bath boards and seats, grab rails, sock aids, long handled shoe horns and long handled grabbers – anything to make life a bit easier is good! 

Adapting leisure and work activities however is more complex as they are so individualised. An important coping strategy for me was re-establishing my priorities, expectations and aspects of my identity. 
For example, in my role as a mother I couldn’t get down on the floor and change my toddler’s nappy, but I could still breastfeed her which meant the world to me. 

We had just moved house and although I couldn’t help move any boxes, I did all the phoning round, changing our address, organising workmen etc. It was about re-adjusting the daily activities (or occupations as OT’s call them) to create purpose and meaning to my day.

Maintaining positive mental wellbeing – There are various self help strategies that patients can use to maintain positive thinking, improve mood and combat stress during difficult points in their rehabilitation. 

Guided imagery or visualisation CD’s; 
Laura Mitchell method & 
progressive muscular method (adapted around hip area); 
Autogenic relaxation; 
colour relaxation; 
diaphragmatic breathing; 
meditation; 
positive affirmations and self talk; 
comedy and laughter; 
reducing caffeine intake; 
eating a well balanced diet; 
following sleep hygiene principles; 
complementary therapies such as acupuncture, 
reiki, 
reflexology, 
hypnosis – can all be very helpful. 

Patients should however seek prompt help from their GP if they are worried they are becoming clinically depressed.

Social support – is crucial for practical and emotional support. Consider your social environment – do you live alone? Are family aware of the rehab period post op and potential support needed? 

Many patients use online forums and blogs for support. Personally I found these on the whole very helpful as I was able to ask questions and seek reassurance in between medical and physio appointments. 
However there is a down side – hearing about cases that haven’t been so successful, or over comparing yourself to others. 
For example I saw a post from a man who had completed a triathlon at 12wks post op! Of course he didn’t say exactly what surgery he had done and I suspect he was athletic and fit before his surgery, but it didn’t stop me comparing that I could only just manage to walk around the supermarket! 
Just remember that recovery time is very individual and no two surgeries, or pre-op circumstances are exactly the same. 

Measuring progress – Range of movement, muscle strength tests, and various standardised questionnaires about pain, daily functioning and quality of life are commonly used as clinical outcome measures. 
However for me it was more meaningful to think back about how I was a few weeks previously and what I had achieved in my daily life – which was of course unique to me. 
However remember to do this with the motto that this rehab is commonly “two steps forward and one step back” and that it may take a whole year to fully recover!

Conclusion

There needs to be a holistic approach to hip arthroscopy rehabilitation. Rest and physiotherapy exercises are important, but patients also need to look after their mental health if they are to achieve the best outcome. 

We know there is a strong link between physical and mental wellbeing. As recommended in the white paper Closing the Gap: Priorities for Change in Mental Health (2014), best practice approaches for physical conditions should include potential psychological care needs. However there needs to be more research done in this area.

By Mandy Graham, BSc (Hons) OT; Msc OSHip Arthroscopy Patient 2014