What if some of these 'conditions' are just normal age-related changes in the joint?
Yes, some causes of hip-related pain are due to changes occuring in the joint which are very normal for the age of the person they belong to, although in younger adults this is less likely to be the case. Some of these things are not age-related and are not 'normal' (whatever 'normal' is) and so, as mentioned previously, these need to be differentiated from each other.
Are we over-pathologising the hip?
It may be true that we have over-medicalised some forms of FAI (but not all). Every hip joint is different and we all, to some extent, may have minor structural abnormalities in any or all of our joints. This is why it is absolutely vital that we put into practice lessons learned in recent pain science research and literature. There are many factors aside from a structural diagnosis which contribute to a person's experience of pain, and caution needs to be taken with what language is used when communicating with patients.
As I've written in a previous post though (click here to read it) the context around Young Adult Hip conditions is also one of 'under-pathologising!' It is true that many young adults visit several health professionals before finding a diagnosis for their hip pain at all. Differentiating between the 'morphologies' and the 'pathologies' is often difficult without radiographic imaging as they can present in a similar way. And, as we know a late diagnosis in a hip condition predisposing the joint to early onset OA usually ends in tears.
Orthopaedic surgeons are biased towards searching for a structural diagnosis and wanting to perform surgery
Yes, clinicians from all specialities and walks of life are at risk of being biased in their practice, towards a certain trend, way of thinking or treatment (physios too, I'm afraid!). Unfortunately those clinicians who don't take into account social, psychological or other factors involved in a patient's pain experience may place too much emphasis on structure as a cause, or may suggest a surgical solution prematurely.
From my bits and bobs of involvement, connecting with and hearing from young adult hip surgeons, I do get a sense that those who treat high volumes of young adult hips take note of psychological and social factors in a patient's life, however, I still have limited experience in practice so I may be wrong. I feel it is important, though, to be working in conjunction with clinicians from other disciplines in regard to these issues, rather than placing them at another end of a spectrum of what is 'right' and 'wrong' in patient care. We, as patients, need you all to work together.
The evidence base is poor
The evidence base around young adult hip conditions is relatively small, and slowly growing, so it would be easy to dismiss research findings on the basis that they are from low quality studies. I don't think these are are all so poor as to dismiss them completely though. The UK Fashion Trial (Griffin et al, 2018) PAO surgery outcomes at 20 and 30 years (Steppacher et al, 2008, Lercher et al, 2017) and comparison of clinical features between FAI and dysplasia (Kappe et al, 2012) are some examples of how correct diagnosis may change the treatment options for a patient. And of course, it goes without saying that evidence-based practice involves weighing up the evidence which exists along with sound clinical reasoning and each patient's individual presentation.
Some people just claim to be 'experts'
This is a seemingly relevant thought in light of the small evidence base and the fact that there are so few orthopaedic specialists who are considered to be able to diagnose and treat young adult hips successfully. I get the impression we have been through previous 'eras' in healthcare in which clinicians may have claimed to be 'experts' at performing a certain treatment or surgery, but with no good quality data or evidence-base to back up that claim. It is obviously better to have clinicians who can back-up this kind of claim with hard data. There's nothing wrong in itself, though, with being an expert and specialising in a certain area. It gives you an understanding of the particular presentation of patients with those conditions and of what approaches tend to work best with them.
Personally, I have preferred having input from physios who specialise a little more with hips in young adults. They have an understanding of the social and emotional consequences of this hip condition and its related surgeries, and of particular quirks us hippies have when doing rehab exercises.
Hip preservation surgery is often unsuccessful, and patients are still in pain afterwards
The outcomes of hip preservation surgery (hip arthroscopy or pelvic osteotomy) have seemed to have been highly variable at times, with lots of influencing factors. This is something which the Non-arthroplasty Hip Registry (www.nahr.co.uk) was set up to tackle. The aim of this registry is to monitor trends in outcomes of these surgeries and make information around these figures transparent. I believe it may become mandatory in the next few years. In the meantime, when considering the success of surgeries it is worthwhile considering psycological and social factors in a patient's life, as well as duration of their symptoms, presence of OA in the joint and individual surgeon's volume and experience.
Some people with labral pathology don't have symptoms
It does seem to be true that some people have acetabular labral pathology spotted on MRI scans but with no symptoms of pain in the hip joint. Perhaps this finding is more relevant in sporting clinics where effort goes into preventative screening of athletes, as I'm unsure as to why a patient in another context would be sent for imaging if they did not have symptoms. If somebody has no symptoms in this regard then... great! They should go and live life, be happy, enjoy activity, and live happily ever after. I would agree that we need to be careful not to over-diagnose where that is unneccessary.
This is similar to findings with other joints and pathologies where those kinds of abnormalities were considered the main driver of a person's pain, but where we now know definitive diagnosis and surgery isn't always necessary. So I believe it is important to explore the best approaches with those patients who do have symptoms suggesting a labral pathology. Unfortunately, it is often necessary to take radiographic findings into account as well as clinical signs and symptoms. This is because labral tears can be caused by an underlying acetabular morphology, and also because some of these morphologies can present very similar but have differing trajectories and treatment options.
Sending a patient for an x-ray is an unnecessary dose of radiation, and doesn't change the treatment
An x-ray for a young adult hip patient who isn't improving with physio input is the best way of viewing the contours of the bones (the morphology of the hip joint). As mentioned previously, findings may well change the treatment pathway, as they may indicate that surgery (Hip Arthroscopy, Pelvic Osteotomy or other surgery) might be an option for that patient.
Why should the hip be treated differently to anything else?
I don't think the hip needs to be treated differently to other joints or body parts when we come to assess and treat it. For every problem a patient presents with, we screen and monitor for more threatening pathology, rule out traumatic onset, and differentially diagnose what's going on, taking into account psychological and social factors involved in or affected by a patient's physical problem. It just so happens that the early symptoms experienced by young adults with hip pain can be subtle, even with certain more severe structural pathologies - some of which may need early intervention surgically. And it just so happens that some of these hip pathologies are notorious for being missed by those less specialised in diagnosis and treatment of them.
Young adult hip patients can get better with physio
Fantastic! I love it when physio works and is effective in alleviating pain and restoring people back to function or sporting activity (although obviously I am biased towards physio being great!). There will undeniably be patients who present with hip-related pain (due to soft tissue or bony structure) and for whom the right kind of targetted physio intervention can be effective at resolving their symptoms. Obviously with those for whom this is unsuccessful further investigation may be necessary. Where this becomes difficult is the anecdotal stories reported by some patients of having symptoms which are highly intermittent over several years, to the point where they believed their hip pain had resolved for a period of time, before returning or worsening. I'm not sure what to say about this, apart from the fact that we, as clinicians can't see into the future. It is true that some with these types of conditions have reported mild and managable symptoms for some years before things getting worse.
As long as we are not dismissive of patients who rebound some time later for whom physio intervention was initially helpful for, then I personally don't see any harm in attempting conservative input to start with. Due to the trajectory some of these conditions seem to take, I think any studies comparing the effectiveness of physiotherapy with surgery need to review outcomes at 5 and 10 years post-treatment. And the outcome measures used need to take into account physical, psychological and social affects of hip pain, impact on relationships (including sex life - yep!), family and working commitments.
Some references
British Hip Society (2018) Non-Arthroplasty Hip Register. Retrieved from: www.nahr.co.uk
Griffin, D. R., Dickenson, E. J., Wall, P. D. H., Achana, F., Donovan, J. L., Griffin, J., Hobson, R. & Hutchinson, C. E. (2018) Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet. 391. 2225-35.
Kappe, T., Kocak, T., Reichel, H. & Fraitzl, C. R. (2012) Can femoroacetabular impingement and hip dysplasia be distinguished by clinical presentation and patient history? Knee Surgery, Sports Traumatology, Arthroscopy, 20. 387-392
Lerch, T. D., Steppacher, S. D., Liechti, E. F., Tannast, M & Siebenrock, K. A. (2017) One-third of hips after Peri-acetabular Osteotomy Surviv 30 Years with Good Clinical Results, No Progression of Arthritis, or Conversion to THA. Clinical Orthopaedics & Related Research, 475 (4). 1154-1168.
Steppacher, S. D., Tannast, M., Ganz, R. & Sienbrock, K. A. (2008) Mean 20-year Followup of Bernese Periacetabular Osteotomy. Clinical Orthopaedics and Related Research, 466. 1633-1644
