Stitch

FAI in Longtime Dancer & PT Resolved with Strength Training

What is your story about?
I'm a 36 year old female with a long history of dancing and hip impingement. It was about 15 years before I reached a place where I felt like my impingement was finally resolving. The approach that worked for me was to begin strength training and learn the hip impingement, and to stop stretching muscles that didn't need to be stretched.
How did your early years dancing contribute to hip impingement?
At age 3 my parents placed me in dance classes and I thrived. Always outgoing as a kiddo, I learned some social awareness for when it was appropriate to perform and when it was less-so. Very rigid rules. No gum. No yawning. No talking in class. No patterned leotards or skirts. And no letting your bum stick out. I'm not kidding. TUCKING YOUR REAR UNDER YOU AND FORCING A POSTERIOR PELVIC TILT AS WELL AS AN ANTERIOR POSITIONING OF THE HIPS WAS NORMAL AND ENCOURAGED. It is aesthetically pleasing to the ballet eye. It is not uncommon to see a ballet instructor come up behind a student and tuck ...(more)
How and when did you begin to notice symptoms?
By age 16, I distinctly remember that my hips felt "stiff" - and they sort of ached all the time. But, as a dancer that was normal, right? I mean I was dancing 6 days a week for about 3 hours a night. Working hard required some amount of pain in order to see results (that was my thinking at the time). But, I do remember that there were times my hips would "clunk", "click" or "pop" and I never said anything to my instructors or other dancers, assuming that was just normal. And sometimes it hurt! If nothing else, it was a creepy feeling. A big lunking pressure in my hip, especially with grand rh ...(more)
How did you eventually receive a diagnosis?
Fast forward eight years to when I was a 2nd year physical therapy student at the University of Washington. We were learning about hip impingement and I literally though to myself: "I have that!" THE INSTRUCTOR WAS LISTING THE SYMPTOMS OF HIP IMPINGEMENT:
  • stiffness in the thigh, groin, or hip
  • deep aching in groin or buttock
  • sharp pain in the groin or buttock when the thigh is moved close to the body beyond 90°
  • sharp pain in the groin or buttock when the thigh is moved across the body toward the opposite shoulder
  • pain with sitting for long periods of time
  • difficulty with weightbear ...
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When did your condition begin to limit normal activities?
By age 25, another year goes by without me taking action. By this time it is 2007, I am newly graduated from PT school and just spent the month of June studying 8 hours a day for my boards. We are talking: sitting, hunched over books and anatomy models in a hard chair ... my hip would be so sore after those study days. I had also taken up running in this last year when I was away from Seattle on my physical therapy internships and was unable to dance as much. Following my licensing exam, I had about week left before my first job as a PT was to start so my now husband (then boyfriend) and I ...(more)
When was your first experience trying physical therapy?
September 2007: I decide to do physical therapy for my hip finally. Myofascial release and massage helped, but hip flexor stretches made things worse as did hip mobilizations. I think the exercise prescription was generally good and well-intended, but as a dancer with butt-tucking tendencies, I fooled my PT into thinking I was using my glutes when I really wasn't. No significant change in symptoms.
When was your first imaging done?
January 2008: MD visit and x-ray. "Negative" for significant findings. No suggestions as to what to do next.
Did you try any alternative treatments?
Feb 2008: series of acupuncture appointments. No change in symptoms.
Did you have to make modifications to your activities of choice?
In Spring 2008, I quit ballet. One of the hardest decisions I ever made because at this point I had been dancing for 20 years. But years of pain and a struggle with eating behaviors made this the right choice. Not an easy option for many dancers...and a conversation that I have with patients on a daily basis. Not asking them to quit, but really reminding them of the impact their activity is having on their condition. In Summer 2008 I added in yoga classes (not hot) and started training for the Seattle Half Marathon. Symptoms continue.
How did the marathon training go?
In early Fall 2008, I did a 17-mile day when training for the Seattle Half (over achiever, novice runner mistake). At about mile 15, had searing pain in the left hip and limped home. Wasn't able to continue training. At this point, not exercising outside of yoga once a week. Symptoms continue. So, in late Fall 2008, I began hot yoga three days a week. Felt great in the moment and absolutely horrible later in the evenings or the next day. Symptoms worsening.
When were you recommended surgery?
In Winter 2009, I asked MD to order an MRI and results were "negative" for labral tear. Referred to Dr. James Bruckner in Bellevue, WA. He noted that I had "clear" bony femeroacetabular impingement in my hips (per that previous x-ray that was "negative" for significant findings) and that I "absolutely" had labral tears. Surgery was recommended. He also reminded me that there is a 40% false-negative rate for acetabular labral tear upon MRI testing so regardless of this "negative" finding, he felt certain I would show tearing if they went in surgically. Spring 2009: 2nd and 3rd surgical consult ...(more)
When did you begin strength training?
In Winter 2008, I started taking body pump classes - felt that I needed some strength training but didn't know where to start. Did this 3 days a week with no increase in symptoms. Basically, this is light weights set to aerobics music. Interestingly, I learned how to correctly hip hinge! Crucial. (Even as a PT who taught these positions, I was unable to correctly achieve them myself!) Spring 2009: started PT again, with a focus on Muscle Activation Technique. Decreased symptoms but still clear weakness. Summer 2009: Becoming clear that strengthening was feeling better than stretching and mob ...(more)
Did you have any setbacks after those breakthroughs?
Spring 2011: flare of symptoms (no clear reason why) and obtained a fourth opinion from Dr. Doug Nowak in Everett, WA when I started having sacroiliac pain in addition to the hip pain. Same thing. "Yes, you are a candidate for surgery." But, let's try cortisone injections to the hips and see if this helps with pain. Started wearing a sacroiliac belt for stability and felt relief with this.
What happened when you tried the cortisone injection?
Winter 2011: Finally obtained cortisone injections. Statistically, cortisone works about 50% the time for hip impingement. As we would expect, the injections worked in one hip and not the other. But, having reduced the pain quite a bit, they bought me time to continue to train my hips correctly in CrossFit and I completely eliminated stretching of the hips. As in, I don't do it! I might stretch my glutes a little with a figure 4 pose or use a lacrosse ball to my buns, but you will never see me in a forced lunge or pigeon pose stretching out my hip flexors. You see, I learned that a tight and p ...(more)
How did you continue to decide not to get surgery at this time?
I continued to decide against surgery because parallel to this timeline, I was beginning to treat a lot of dancers with hip impingement. I was observing very mixed results in the patients who were coming to me after surgery. Not enough positive outcomes for me to choose surgery when I still had so much strengthening to do. Additionally, we do not have long-term data to determine how patients who did have surgery compare with those who didn't. I even had a few patients who said they were worse and wish they had never undergone the procedure. Ugh! What to do!?
Where are you at currently with managing your condition?
By the time 2013, rolled around, I had been having hip pain for 15 years. I was 30 and had been doing weight training for 4 years and CrossFit for 2. I hadn't danced in 5 years and hadn't done yoga in over a year. Honestly, I felt better than ever. And, this has continued to be the case!! The reality is that I do not have hip pain regularly any longer. Today, 9 years have gone by since I stopped dancing and stretching. That, combined with 8 years of strength training has really changed my symptomology. And who, in a million years, would have thought this ballerina would be weight training and ...(more)
As a PT, what have you observed in your clinic regarding this condition?
I will be honest, far too many dancers leave the dance studio only to find themselves in a hot studio "winning" at yoga - they are so flexible and it feels good in the moment. But, I wish they would reconsider. I wish I had found strength training (and my booty) earlier in life. Not only do my legs look better, I literally FEEL BETTER! No need to become a CrossFit athlete or squat over 200#, but please commit to learning to hip hinge and getting out of your butt-tucking behavior. Educating my patients about this process and helping them to manage their expectations of recovery is crucial beca ...(more)