July 29, 2025 • 26 mins
In response to a request, we share valuable resources for learning about femoral acetabular impingement (FAI) and labral tears, addressing the knowledge gap many clinicians face with these conditions.
• Four essential resource categories: research literature, clinical specialists, surgical resources, and academic educators
• Key research documents include the Warwick Agreement and Doha Agreement on diagnostic criteria for FAI
• Following clinicians like Dan, Mike Ryman, and Mike Voigt who combine research with extensive clinical experience
• Surgical textbooks like "Hip Preservation Surgery" provide valuable insights despite their cost
• Observing actual hip surgeries offers unparalleled perspective on the procedure and recovery process
• Understanding imaging measurements (alpha angle, lateral center edge angle) improves communication with surgeons
• Interdisciplinary conferences and continuing education courses provide opportunities for professional networking
• Watching a family member recover from surgery builds empathy for what patients experience beyond clinical visits
Your best approach to mastering hip FAI and labral tear management is to combine evidence, clinical expertise, surgical knowledge, and academic insights while applying this systematized approach to any joint or condition.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 2 (00:05):
every day.
You essentially pay your duesby doing the harder thing when
it's the right thing to do.
Back in action.
Another week, exhausting weekin the clinic.
You know really tired.
Long seven days between thesepodcasts wink.
What's new, what's excitingfrom the last seven seconds ago
when we recorded I brought mydog in here, oh nice, where's he
(00:27):
at marvin team marvin, heactually recognizes uh I other
update I have to share.
This morning I'm working out atthe y, where I used to coach,
and so every time I walk to thewindow and like, look between
sets, I see like the old coachesor like people that are now
there, I don't recognize anybody.
(00:47):
There's not a single gymnastthat I used to coach.
There's two.
There's two girls that are likemaybe now in like high school
that I recognize, but literallynot a single person that I used
to coach is still like they'veall grown up and graduated and
now they're coaching.
So feel old.
Speaker 1 (01:01):
Yeah, there's nothing that makes you feel older than
when you're like kids that youused to coach, or like like I
have kids that I used to coachwhen I was younger that are like
married and having kids and I'mjust like I don't know.
It makes me feel certain.
Speaker 2 (01:14):
Yeah, my funny story always is I posted about this
this week but Kylie was like oneof the first gymnasts I treated
at my first job, bay state, andshe was 13 when I have out
there and her teammate, emma andEmma was 13 when I about her
and her teammate Emma, and Emmawas a little older than her, but
so Kylie like triggered her allthrough high, middle school,
high school and then college andthen now she works at champion.
Wow, so meta.
Yeah, she.
She did an internship and atthe time one of the strength
(01:37):
coaches was leaving.
So she's now there and, uh, Iwas walking by the strength side
where they do assessments andshe was doing an eval on another
gymnast who's young and likesuper duper talented and has
been with us for like PT, butnow she's starting strength
conditioning, so she was nowevaling like the next 14 year
old version of herself and I waslike bruh, what is going on
(01:57):
right now?
Yeah, I feel like it doesn'tmake you feel super old.
Like, once I start treatingsomeone's kid like somebody that
I treated as in high school orcollege goes on in 10 years from
now I treat like their daughterwho's in gymnastics for classes
and it's going to be too muchto handle.
I'd be too much inception there.
Speaker 1 (02:11):
You'll just have to retire, right then.
Speaker 2 (02:14):
I think I'll say I had a good run and I'll just
move on to, like, you know, dogwalking or something like that.
Yeah, um, uh, okay, so this isthe second uh series of
submitted questions.
Slash submitted um instagramrequests for podcasts.
So we did a back pain one.
So this one was.
I forget her name.
(02:34):
I'm so sorry, I think it was nome.
Yeah, nope, nope, nope.
Somebody else submitted um, whatare the best resources to learn
about hip, fai and label tears?
So I thought that'd be a goodone to do.
We've talked a little bit aboutit but like, yeah, we were
talking to the last episodebefore recording that, like FAI
didn't exist.
When I was in grad school, Ilearned nothing about label
tears, like literally nothing.
A lot of hip OA, um, a lot of,like you know, muscular strain
(02:58):
sprains, hamstring strains, um,but I really didn't learn a lot
about like slap tears in the hipand labral repairs in the hip
and all the surgery andpreservation stuff going on.
So, um, I kind of had to trialby fire that whole section, not
to mention the other side of thecoin, which is like micro
instability and like laxitybased hips, gymnastanches,
whatever.
So FAI was first and I kind ofgot like a fire hose for that
(03:19):
and then I found like, oh God, Ihave a whole like half of my
schedule that has no bony issues, they have no FAI, they're just
like the super doobie loosepeople.
So yeah, that was the otherside of the equation, which we
won't talk about today.
But what about you?
Did you get that in school, orwas FAI something that came
after?
Speaker 1 (03:33):
Yeah, no, we got all that.
Speaker 2 (03:34):
Oh right, you went to Duke.
Speaker 1 (03:35):
Yeah, yeah.
Speaker 2 (03:36):
Shout out Ryman.
Yeah it, ryman's the man.
He's one of the resources thatwe'll have.
But yeah, you probably got theperfect education on hips.
I got everything about it.
He loves the hips.
So, yeah, it's great.
I mean, I think it's likesomething that you know.
Back pain was the big rage, Ithink, probably earlier, but
then like FAI, and especially inthe sporting context, if you
work in sports like a athleticpubology, fai is like super du
(04:04):
clinic with like far is ityounger kids that are more like
growth plate stuff um, a lot.
Speaker 1 (04:09):
I feel like I see a lot of fa, whether that's like
pre-op, potentially pre-op ornon-op or post-op, so kind of
the full spectrum.
I feel like they do always tryto do like some sort of like pt
prior to going down the surgeryroute, unless it's like a Um.
But we see quite a lot of themactually, but most of them are
about, like I want to say, 15plus.
Speaker 2 (04:32):
Yeah so.
Speaker 1 (04:33):
I feel like I get a lot of like 16 year old girls.
Speaker 2 (04:37):
Yeah, generally it's like 16 plus is when, like the
bones and growth plates havefused so the stress starts to
shift to like passive tissueslike labral and joint.
So that makes sense.
Um, yeah, and I think I wouldagree.
I see a lot of these too aswell.
I think we have a lot ofsurgeons that are like hip
preservation surgeries betweennew york city and boston that
trying to help a lot of peoplekind of preserve as much as
possible long term, because onceyou're starting to get to like
(04:58):
cartilage damage and microfractures in the hip it's really
spicy.
So if you you can preserve, youknow, labral tissue and the
cushioning it's really good.
So FAI for those that areunfamiliar as femoral acetabular
impingement and generally itspeaks to like a symptomatic
abnormal contact of the hipjoint, so like the femoral neck
on the acetabular rim andgenerally FAI.
You know FAI can come withouttons of bony changes, but most
(05:21):
commonly somebody has repetitivestress from a running sport, a
sprinting sport, you know, likedeep squatting, something that
causes football, for example,that causes like Wolf's law to
come into approach.
So as they hit the femoral neckon the hip over and over again,
a little bit of bony overgrowthstarts to happen, maybe on the
hip side, which would be calledthe pincer lesion, or the thigh
(05:42):
side called a cam lesion.
So essentially now it's like anegative feedback loop that the
more bone that is laid down tokind of protect that area
against abnormal stress, themore contact starts to
approximate and then over timeyou can start to squish some
important structures soft tissue, capsular tissue and then most
times, like the labrum itselfstarts to become damaged, which
you know.
When the labrum becomessymptomatically damaged and it
(06:03):
starts to affect, like, thestability of the hip, that's
when you need to kind ofconsider a PT options or things
like that.
So, um, resources wise, I kindof have four buckets here, but
I'm happy to maybe investigatesome of this.
But I kind of found thatresearch stuff really high
quality research studies um,clinicians who are treating
these people, surgeons who areoperating on these people, and
then like academics who aredoing research in universities,
(06:25):
are probably the best things.
That's how I learned prettymuch all this, and so just a
couple examples here, probablylike one really good one to
start with is the work agreement.
So this is essentially like abunch of really smart people
getting together.
Mark Philippon, you knowRyman's on there too as well,
tons and tons of really smartpeople just getting together and
trying to kind of like build aninterdisciplinary framework of
like how to manage these peopleand like what's the best course
(06:45):
of action and like what is thekind of wouldn't be a clinical
prediction rule, but more solike what are the things that
are important to know whethersomeone's going to do well or
not do well with surgery or notdo surgery.
And the Doha agreement isanother one which is more about
classification.
But essentially a lot of thesestudies Doha, warwick and some
other stuff have just shown that, generally speaking, on exam
you want to have somebody whohas a consistent, provocative
(07:09):
sign of FAI with, like flexionor internal rotation or
adduction or some degree ofcutting and pivoting that mimics
mechanical symptoms.
Right, so they could have likepopping, clicking, catching as
well, but generally speaking ithas to be repeatable.
So that's kind of one thing.
Two is that they want to makesure that MRI findings are
relevant to the current case ofpain.
So they have to have MRIfindings that match the symptoms
(07:32):
they present with, becausethere's a lot of things around,
like groin issues or abdominalhernias or sports hernias or
other things that areoverlapping that maybe you get
an MRI and it shows you have alabral tear, but it doesn't
necessarily, it's notnecessarily causing your pain
right now.
You know 50% of hockey playershave a labral tear.
That's not symptomatic, right?
So just because the sportdemands same thing with baseball
(07:53):
and shoulders.
And then, third piece of many ofthese is that diagnostic
injection is typically veryuseful for these folks to figure
out if we take light again or acortisone injection and we
inject it into the hip joint andyour pain gets better.
That tells us that you knowthese people are probably
getting symptoms from withintheir joint versus, if that does
not happen, whether pain doesnot change at all despite an
injection into their hip.
(08:14):
They might do a lidocaineinjection to like the hip flexor
or the rectus femoris and thentrying to denote whether it's
intra or extra articularreferral, right.
So those three things.
And then typically people whohave mechanical symptoms and
also have the presence of bonychanges, so cam or pincer
lesions.
Those people tend to not dogreat with conservative care
because, yes, you are symptommanaging, yes, you are helping
(08:38):
with some like kinetic chainfactors, yes, you're managing
workload, but you know if therock in your shoe,
metaphorically has gotten so bigand it's stuck that it's
rubbing against your foot everytime you step on it.
Sometimes you know, justreducing that cam lesion or that
pincer lesion is reallyimportant to not have continual
progression of labral damage,along with maybe repairing a
labrum and stuff like that.
So Warwick and Doha, I thinkthis is more about like
diagnosing groin pain and kindof making sure we have the right
terminology for it.
(08:58):
And then there are some reallygreat exercise or journal
articles this is from theJournal of Athletic Training,
but there's been other ones tooas well that essentially are
going through what FAI is, youknow what their symptoms are,
what they tend to have, and thenlike some diagnostic criteria
and things for eval and thenthings for treatment.
So that's kind of my alwaysgo-to bucket is like a review of
the literature on like whatkind of things are available for
(09:20):
agreement consensus statements,randomized controlled trials,
systematic reviews, reviews, bigpicture stuff, um, and then
clinical, you know single coursetrials that are like
double-blinded gold standard forlike treatment is really good
too.
But I know evidence kind of istop of mind for me, um,
different thoughts on that nowI'm pretty much on the same page
with all that stuff yeah, right, and you guys, this was all
(09:40):
open, this was already availablewhen you guys came out of
school, right?
you guys had all these dang Dangand I'm jealous, bro, yeah,
2016.
I forget when the Delhaagreement was, but yeah, so
that's the first thing youshould do is you should um head
to PubMed and you should readthose three articles, but then
also look at a lot of the otherarticles that have notable
(10:03):
authors that I know are in thefield.
So like there's two or threehip surgeons like Dr Kelly, um
Calcivart, um Philippon it'slike a bunch of like hip
surgeons that all they've donetheir whole life is kind of like
hip surgery and like laborrepairs, and then, of course,
pts Ryman, mike Voigt they workwith a lot of hips.
So if they're publishingresearch on things, you know
it's probably gonna be relevantthat you want to keep up with
(10:23):
that, and so you just save theirnames in like a PubMed search
and every once in a while you dolike a one year search and
review about all the articlesthat have come out in the last
you know, whatever year or twoon those authors.
Or you can track the table ofcontents in public journals like
the preservation surgeryjournal or sports health or
things like that, and then justflag any like label type things.
(10:44):
So that would be.
My first step is, you know,maintenance care, I would say,
to try to keep yourself up todate on some new stuff that
comes out.
The second piece is to try tofollow clinicians that are in
the clinic but are also maybehave content, websites and stuff
.
And so Dan always comes to mindwith me is like Dan is a very
smart, very hardworking dude andhe spends half his life with
(11:05):
people who have these problems,so he's actively reading the
research but then he's treatingpeople right for all these types
of issues.
So you know dan has a podcasthere on fai I think it might be
with kevin and stuff, but it'slike 35 minutes of going through
how he diagnoses it, how heinterprets the research, how he
treats it, and then kind of getsinto more of like the not as
clinically or not asevidence-based, uh proven.
(11:26):
That like this is how you treatsomebody who's a football
player, who's going back torunning and cutting and pivoting
and they they're in the sixmonths after the labor repair.
The research sometimes falls offon specific categories for like
advanced strength, conditioning, power, plyometrics.
Return to sport.
So Dan is a really goodresource because he's obviously
gone through this himself, buthe has lots of very relevant,
helpful things.
So there's a there's a handfulof people that I think I have in
(11:46):
like buckets in my mind fordifferent online educators.
So, dan, obviously I sit at thedesk next to you, so it's a
little bit obvious for me to sayhis name, but, like you know,
mike Ryman, mike Voigt, likethose people are working with
these types of surgeons andthese types of people all the
time, and so just have bucketsin your mind of those that are
maybe working with thepopulations that you want.
I feel like you found us fromDuke for champion, but then you
(12:06):
probably have a network ofpeople down there that you
connect with for clinical casesor things that are like common
surgeries, right?
Speaker 1 (12:12):
yeah, I feel like I got a lot of my like mentoring
from one of our like through myresidency program, one of our
like mentors, and I feel likeI've got aside from like you and
then at duke, I feel like I geta lot of my like hip advice
from him and then he worksreally closely with one of like
the surgeons on like some hipresearch.
That's not necessarily for fai,but it's a little bit more for
(12:32):
like adult hip pain.
I guess I think he's doing like, I don't think he's doing hip
replacements, I don't remember.
But, um, he does a lot ofresearch on hips and stuff.
So he gets a lot of his likesupplements, his evidence that
he gets in clinic and like fromtreating people in addition to
like the surgeon side of things.
So he gets both all the time,which I think is really helpful
(12:53):
because you really get to seelike both sides of what the
surgeon sees on the imaging andlike what is eval.
And then he gets his side fromlike PT, from treating a bunch
of them all the time and I feellike I've soaked up a lot of his
knowledge too.
Speaker 2 (13:06):
Yeah, and I didn't have this in the outline, but I
just thought of this is that youknow, I think going to like not
surgical meetings maybe, butlike interdisciplinary meetings
is really, really helpful.
Um, I think a lot of thehospitals in Boston at least I'm
not sure if they do this inother areas, but they'll do like
a once per year or once everyother year kind of like I don't
know multidisciplinarypresentation.
The thing that I hate aboutthese presentations they're all
(13:28):
like the presentations are 20minutes long and they just rip
through like 400 things thatthey have to go through.
But it's a really good way tosee a bunch of different
surgeons or clinicians who arelike treating these people when
doing research.
I think the one around here islike New England Baptist will
always put on like some giantyou know orthopedic kind of
conference and a lot of it is avendor shilling for like buying
products, but you'll have likean hour of lectures, 30 minutes
(13:57):
off an hour of lectures and youknow, get your PT place or
whoever you're with to pay forit and uh, it's a super good way
to hear from surgeons that youknow are in your area that are
literally doing the surgeries onpatients that are probably
coming to you and then you knowyou like wait for the right
moment and you try to, like youknow, have an intelligent
question, smooch a bit and go upafter the thing.
Oh yeah, I worked on the roadthis place, like I met a lot of
the surgeons that champion worksnow through Mike, but then I
met a lot of them also just viabeing at meetings, listening,
trying to ask good questions,emailing, following up, you know
(14:19):
, going to appointments withsome of my patients that were
going to get surgery and justsaying like hey, is it cool if I
sit in and like just talk,touch base with this person?
Um, you get a lot of reallygood networking there and, of
course, they're going to sharewith you things that they think
are really important and you'regoing to learn passively from
all the research that they'rereading, you know.
Speaker 1 (14:34):
Yeah, and I do like sitting out on appointments.
I think that's been reallyhelpful for me, particularly for
the hip, and I think the back,but sitting in and watching what
they do to evaluate and howthey make their clinical
decisions is really helpful tolike see that background.
And it's helpful from aneducational standpoint too for
your patients when they come inand they're wondering, like
should I get surgery, should Inot?
(14:54):
Like they're asking you allthose questions too.
Speaker 2 (14:56):
So having an idea of kind of both sides of like what
your clinical opinion is, butthen also what, having the
knowledge of like what thesurgeon is looking at too, so
you can kind of anticipate whatthey're thinking as well, yeah,
right, and so there's no betterperson to get like anatomy level
, biomechanical level and orevaluation tools from the
surgeon, because those peopleare using those tools to
(15:19):
determine whether they're goingto cut into this person and do a
huge surgery.
So you want to make sure thatyou're using the diagnostic
tools.
Obviously, like treatment wiseand exercise is kind of more our
bag.
But the evaluation that thingsare looking for in imaging,
x-ray, mris that you know Iusually do an in service for the
people at Champion and like wego through some of that surgical
, you know, or imaging basedthings they look at like an
alpha angle and a cam lesionwhat's that look like?
(15:41):
And a lateral center edge angle.
Like it's important for us asPTs to know what these things
are.
Not that I would diagnose thaton imaging I'm not a radiologist
but if somebody comes with animaging finding it has a bunch
of these angles.
You need to know what they meanand what's significant versus
what's not, which ironicallyleads to the next kind of
resources that you know thisbook is a $900.
These two textbooks is $900.
So like I wouldn't go investyourself, um, but a clinic.
(16:02):
You know, if you have a clinicthat is seeing nonstop hip labor
repairs and all sorts of otherinjuries in a sporting
population, you guys should tryto do a bake sale and you should
try to raise money to buy thesetwo textbooks and have them on
your shelf.
Because you know I wasfortunate that, like when this
came out, I was like peak shiftmode and so I was like using the
money from consulting andteaching to reinvest in my book.
(16:24):
So I had these two and I readthem, but like having that book
access to you when a weird funkylabor repair comes in with our
PAO which you've never treatedbefore, like you really want to
know like how these surgeons aredoing these um surgeries and
what they look like.
So you know, not all thesechapters are relevant because
some of them are like whatscalpel to use and like how to
suture you know a hip it's likemaybe that's not the most
(16:44):
important for you, but a lot ofthese things are combination of
PT advice from really goodsurgeons that have working with
them or protocols, but then alsoyou know when they do a label
repair or cam reduction, likewhat are they doing?
Where are they cutting, whereare the port-a-holes goal?
You want to know all that kindof stuff because it matters.
If you have a better command ofthe surgery they're doing,
you're going to be able to makegood decisions.
(17:04):
And also, like, the first threechapters of this book are like
thick, thick anatomy andbiomechanics stuff which, like
if you're working with thesepeople, you really gotta, you
know, do your due diligence toknow about you know, I mean yeah
, definitely, and I think Ipushed this in one of the last
podcasts too.
Speaker 1 (17:18):
But I I feel like I have learned just so much more
by sitting in on a surgery.
Yeah, just watch it, see itlike even if they're doing like
an arthroscopic surgery, you'restill watching them like take
the x-rays in between each, likecut that they're doing and like
they're in their element, sothey're teaching everything that
they're doing.
And then if there's like amedical resident in there, then
(17:38):
they're also teaching themeverything they're doing.
Speaker 2 (17:39):
I feel like you just learned so much yeah, it gives
you a much better appreciationfor you know why people are
sometimes so cranky and arereally going through it.
Two, two things that wereeye-opening for me.
One is that I actually mymother, my mother had shoulder
surgery, a rotator cuff repair,with Dr Ramappa locally in
Boston.
I've treated a hundred ofRamappa's patients but I see
them like for an hour a weekpost-op or two weeks post-op and
(18:01):
they go home.
I don't spend the other 23hours of them being with my own
mother through the entire nightand watching her like struggle
and pain meds and sleeping andbathroom Like.
I really had a much betterperspective on like why people
are really tired and reallycranky and are really having a
tough time and how hard it is,particularly in the first two
weeks of a big surgery, hipwhatever.
It gave me a lot of perspectiveand empathy.
Knowing what's going on on theother side of the kind of
(18:23):
appointment too is to your point, as I watched a lumbar fusion
surgery in grad school and youknow when you watch a lumbar
fusion surgery or an ACL repairor a total hip replacement, it
is not delicate dog, it is not.
It is not like these very likegradual, slow cuts.
It is like Home Depotconstruction.
Sometimes orthopedics is prettygnarly, so you understand why
(18:44):
it's a bit more, uh, invasive.
And then also why somebody'ship or their knee might be
throbbing and killing themimmediately post-op, why you got
to go slow and drugs are okayand ice is a good thing.
You know, like these, thesethings are in place for a reason
and not to always just kind oflisten to like the social media
swing of like never ice, anybodyever.
It's like all right, that isclearly misguided guidance.
Sometimes some post-op cuff orknee repair ice is probably
(19:06):
helpful, because I'd rather doice than shit ton of Viking.
You know, um, I had one more.
Oh right, I mean, yeah, last oneI would say is, uh, academic
people.
So I'm a big fan of clinicianswho are academic teaching, but
they also go out of their way toteach courses.
So, um, I think both areimportant.
I think clinicians who teachcourses and academics doing
research who also teach coursesand maybe do clinic stuff as
(19:28):
well.
Like you need both.
You need the academic point ofview and to kind of understand
the research really well.
Mike is like ridiculous on howmuch research he can process and
synthesize and he runs his ownresearch he's on the doha
agreement or the work I figureit's one but like someone who's
in the trenches, who takes timeout of their busy life and their
family to make a course for youon like all the things they
think about, probably importantto to go about that.
(19:49):
So I took this course veryhelpful, but that I think I view
this a little bit differentlythan someone like Dan, for
example, who's primarily aclinician and happens to read
research and interpret that andapply that.
So, um, I know it can beexpensive for con ed, but I mean
between your own budget andbetween like a course that your
clinic can all kind of takeadvantage of, there's definitely
something to be said about it.
Like you want to take this hipcourse and you split it with
(20:10):
your employer and then your jobto pay back your whatever half
you didn't pay for is to likemake an in-service and present
it to like your coworkers.
Like, if you're not in a clinic, that's open to the idea of
that bro, like finding a clinic,but like that's a very
reasonable thing to do is like,all right, once per month or
once every two months, we'll payfor you to take a course and
then your job is to kind of likedo an in-service for us so that
we can all get better, likethat's a fantastic way to run a
(20:31):
Con Ed clinic along with.
You might just really want tolearn about it.
Maybe it's on sale for ahundred bucks and you want to
buy it yourself and inhale it ona weekend.
You know it can be expensive,though.
Speaker 1 (20:39):
I'm not going to front.
Speaker 2 (20:40):
You know, I know it's expensive.
An $800 textbook is a littlerough.
Speaker 1 (20:43):
Yeah, that's, that's a lot.
Speaker 2 (20:56):
I'm looking at my shelf and there's like a
shoulder textbook with Mike andMike and James Andrews they
wrote that two volumes of thehip preservation one are pretty
good.
There's an ankle, one is a kneedisorders one with Frank noise
who's kind of like one of thegodfathers of like knee rehab or
knee surgery.
So yeah, like each joint hasthese like big, big textbooks
that are probably good for aninvestment to kind of keep your
eye on.
And you know I don't think I'veread them cover to cover but
(21:18):
like I've definitely handled allthe chapters that I think are
most relevant to me.
And then I can't tell you howmany times I've had to go back
and research.
Like I remember the first time Itreated like treating an elite
gymnast with a huge PAO and thesurgeon and I talked for a long
time and he's like, yeah,there's a lot of good research
on like these very lax, fullyskeletally mature adult females
who have this issue and theywant to get back to casual
running and you know, likestrength training, I was like
(21:40):
all right, cool bro.
But like this is like a 17 yearold lead gymnast who has a
scholarship on the line, he'slike yeah, yeah, good luck with
that and I was like awesome.
So I had to read like all, yeah, he was a phenomenal surgeon.
Her surgery went really reallywell.
But like once we got past like24 weeks and it was like past
the oh no phase.
Um, he was more just like, yeah, we're gonna have to progress
based on how you feel, as goodwith strength conditioning, and
(22:01):
as long as she's not gettingworse, we'll just keep cruising
along.
So it's kind of like the wildwest and I was just like reading
those textbooks and trying tounderstand the anatomy as much
as I could.
Yeah, a lot of trial and error.
You know there's no rcts on howto treat an elite gymnast with
a pao.
Speaker 1 (22:13):
You're kind of just like shooting by the hip yeah, I
feel like I don't see very manypaOs and like older kids, I
feel like I see a lot of youngerPAOs, variations of a PAO, and
like kids that aren't fully like, their bones aren't fully
formed yet.
Speaker 2 (22:25):
Yeah, it was a last ditch effort.
Unfortunately, she was not acandidate, for she had no bone
illusions.
She had no cam, no pincer.
Speaker 1 (22:31):
She's just very, very lax, or like dysplasia was at
an all time high but that's whatmade her angles that you're
talking about, I feel like comeinto play a lot like having a
good idea of like what thesurgeon's measuring in there,
because I went through all ofthose like types of measurements
with the surgeon and like putthem all out on like a diagram
and it was really helpful tolike have those like pieces in
mind when you're looking at liketheir x-rays.
Speaker 2 (22:52):
Yeah for sure, and some of those surgical textbooks
like they're so dense with liketwo pages of writing will give
you so much information that youhave to really stop and like
write it out and maybe look atmore stuff.
But like all that stuff camalpha angle, lateral center
energy angle, anterior centerenergy angle, like crossover
sign, how they measure all thosethings is helpful and there's
probably like there's like 50,right, but out of 50, there's
(23:14):
probably 10 that are reallyrelevant and you just want to
have a working knowledge of sothat you can kind of be
conversational.
Maybe if you see them or ifthat radiology report comes
through they, you know they getthe MRI done and they just send
you a screenshot of the findingsbefore they see their surgeon.
You can have a little bit of aoh, this is kind of what it
seems like here and you have abetter kind of head on your
shoulders to know, like wherethis person's coming from before
(23:34):
they see the doctor yeah, andit helps with, like your
justification, I feel like, orthe I, the surgeon's
justification for why they'retotally proceed with surgery.
Speaker 1 (23:42):
Because I feel like I get a lot of like parents and
patients that are like, do wereally need this?
Like yeah, like they're stillkind of like questioning,
especially if they were doinglike a just like therapy before
they decided surgery or not andare they waiting on imaging.
So it helps you kind of likegive them an idea to and be
knowledgeable and like if that'sthe justification, like a lot
of times, like our surgeons willput that in there for their
(24:03):
justification, yeah, especiallylike okay, yeah.
Speaker 2 (24:09):
And I view it the same as like when you do
strength numbers and you'redeclaring someone to run after
an ACL or not.
You need objective numbers ondining, like dynamometer testing
and jump testing and all thatkind of stuff.
Like that's very much like theglue of why we make decisions is
like some of these decisions,especially in sports, are a very
big deal for someone to takesix months off or to go back
earlier to not.
So you do the best you can, but, like you need as much
objective, factual informationto base these things, to make
(24:34):
clinical judgment as possible,and not just like well, you know
, I think we're ready, youquestions like that.
I think that, though, alone isprobably good for those people
to get started and take thatsystemized approach of like
evidence clinicians, surgeons,academics and you can apply that
to any joint or thing you wantto learn about.
So sounds good, cool beans.
Speaker 1 (24:51):
I feel like we could do like a whole separate, like
episode on like treatingdifferent buckets and like how
you approach that with likepeople who have like more bony
overcoverage versus deeperhyperbolo.
Speaker 2 (25:02):
Like overcoverage, undercoverage.
Oh yeah, definitely.
We'll put that for the next oneFAI versus dysplasia, hyper
versus hypo.
I'm down with that.
I just did an internship, Ijust did an in-service on that.
I'm pretty good with that TBDAlright.
Bye everyone.
Speaker 1 (25:19):
Bye.
every day.
You essentially pay your duesby doing the harder thing when
it's the right thing to do.
Back in action.
Another week, exhausting weekin the clinic.
You know really tired.
Long seven days between thesepodcasts wink.
What's new, what's excitingfrom the last seven seconds ago
when we recorded I brought mydog in here, oh nice, where's he
(00:27):
at marvin team marvin, heactually recognizes uh I other
update I have to share.
This morning I'm working out atthe y, where I used to coach,
and so every time I walk to thewindow and like, look between
sets, I see like the old coachesor like people that are now
there, I don't recognize anybody.
(00:47):
There's not a single gymnastthat I used to coach.
There's two.
There's two girls that are likemaybe now in like high school
that I recognize, but literallynot a single person that I used
to coach is still like they'veall grown up and graduated and
now they're coaching.
So feel old.
Speaker 1 (01:01):
Yeah, there's nothing that makes you feel older than
when you're like kids that youused to coach, or like like I
have kids that I used to coachwhen I was younger that are like
married and having kids and I'mjust like I don't know.
It makes me feel certain.
Speaker 2 (01:14):
Yeah, my funny story always is I posted about this
this week but Kylie was like oneof the first gymnasts I treated
at my first job, bay state, andshe was 13 when I have out
there and her teammate, emma andEmma was 13 when I about her
and her teammate Emma, and Emmawas a little older than her, but
so Kylie like triggered her allthrough high, middle school,
high school and then college andthen now she works at champion.
Wow, so meta.
Yeah, she.
She did an internship and atthe time one of the strength
(01:37):
coaches was leaving.
So she's now there and, uh, Iwas walking by the strength side
where they do assessments andshe was doing an eval on another
gymnast who's young and likesuper duper talented and has
been with us for like PT, butnow she's starting strength
conditioning, so she was nowevaling like the next 14 year
old version of herself and I waslike bruh, what is going on
(01:57):
right now?
Yeah, I feel like it doesn'tmake you feel super old.
Like, once I start treatingsomeone's kid like somebody that
I treated as in high school orcollege goes on in 10 years from
now I treat like their daughterwho's in gymnastics for classes
and it's going to be too muchto handle.
I'd be too much inception there.
Speaker 1 (02:11):
You'll just have to retire, right then.
Speaker 2 (02:14):
I think I'll say I had a good run and I'll just
move on to, like, you know, dogwalking or something like that.
Yeah, um, uh, okay, so this isthe second uh series of
submitted questions.
Slash submitted um instagramrequests for podcasts.
So we did a back pain one.
So this one was.
I forget her name.
(02:34):
I'm so sorry, I think it was nome.
Yeah, nope, nope, nope.
Somebody else submitted um, whatare the best resources to learn
about hip, fai and label tears?
So I thought that'd be a goodone to do.
We've talked a little bit aboutit but like, yeah, we were
talking to the last episodebefore recording that, like FAI
didn't exist.
When I was in grad school, Ilearned nothing about label
tears, like literally nothing.
A lot of hip OA, um, a lot of,like you know, muscular strain
(02:58):
sprains, hamstring strains, um,but I really didn't learn a lot
about like slap tears in the hipand labral repairs in the hip
and all the surgery andpreservation stuff going on.
So, um, I kind of had to trialby fire that whole section, not
to mention the other side of thecoin, which is like micro
instability and like laxitybased hips, gymnastanches,
whatever.
So FAI was first and I kind ofgot like a fire hose for that
(03:19):
and then I found like, oh God, Ihave a whole like half of my
schedule that has no bony issues, they have no FAI, they're just
like the super doobie loosepeople.
So yeah, that was the otherside of the equation, which we
won't talk about today.
But what about you?
Did you get that in school, orwas FAI something that came
after?
Speaker 1 (03:33):
Yeah, no, we got all that.
Speaker 2 (03:34):
Oh right, you went to Duke.
Speaker 1 (03:35):
Yeah, yeah.
Speaker 2 (03:36):
Shout out Ryman.
Yeah it, ryman's the man.
He's one of the resources thatwe'll have.
But yeah, you probably got theperfect education on hips.
I got everything about it.
He loves the hips.
So, yeah, it's great.
I mean, I think it's likesomething that you know.
Back pain was the big rage, Ithink, probably earlier, but
then like FAI, and especially inthe sporting context, if you
work in sports like a athleticpubology, fai is like super du
(04:04):
clinic with like far is ityounger kids that are more like
growth plate stuff um, a lot.
Speaker 1 (04:09):
I feel like I see a lot of fa, whether that's like
pre-op, potentially pre-op ornon-op or post-op, so kind of
the full spectrum.
I feel like they do always tryto do like some sort of like pt
prior to going down the surgeryroute, unless it's like a Um.
But we see quite a lot of themactually, but most of them are
about, like I want to say, 15plus.
Speaker 2 (04:32):
Yeah so.
Speaker 1 (04:33):
I feel like I get a lot of like 16 year old girls.
Speaker 2 (04:37):
Yeah, generally it's like 16 plus is when, like the
bones and growth plates havefused so the stress starts to
shift to like passive tissueslike labral and joint.
So that makes sense.
Um, yeah, and I think I wouldagree.
I see a lot of these too aswell.
I think we have a lot ofsurgeons that are like hip
preservation surgeries betweennew york city and boston that
trying to help a lot of peoplekind of preserve as much as
possible long term, because onceyou're starting to get to like
(04:58):
cartilage damage and microfractures in the hip it's really
spicy.
So if you you can preserve, youknow, labral tissue and the
cushioning it's really good.
So FAI for those that areunfamiliar as femoral acetabular
impingement and generally itspeaks to like a symptomatic
abnormal contact of the hipjoint, so like the femoral neck
on the acetabular rim andgenerally FAI.
You know FAI can come withouttons of bony changes, but most
(05:21):
commonly somebody has repetitivestress from a running sport, a
sprinting sport, you know, likedeep squatting, something that
causes football, for example,that causes like Wolf's law to
come into approach.
So as they hit the femoral neckon the hip over and over again,
a little bit of bony overgrowthstarts to happen, maybe on the
hip side, which would be calledthe pincer lesion, or the thigh
(05:42):
side called a cam lesion.
So essentially now it's like anegative feedback loop that the
more bone that is laid down tokind of protect that area
against abnormal stress, themore contact starts to
approximate and then over timeyou can start to squish some
important structures soft tissue, capsular tissue and then most
times, like the labrum itselfstarts to become damaged, which
you know.
When the labrum becomessymptomatically damaged and it
(06:03):
starts to affect, like, thestability of the hip, that's
when you need to kind ofconsider a PT options or things
like that.
So, um, resources wise, I kindof have four buckets here, but
I'm happy to maybe investigatesome of this.
But I kind of found thatresearch stuff really high
quality research studies um,clinicians who are treating
these people, surgeons who areoperating on these people, and
then like academics who aredoing research in universities,
(06:25):
are probably the best things.
That's how I learned prettymuch all this, and so just a
couple examples here, probablylike one really good one to
start with is the work agreement.
So this is essentially like abunch of really smart people
getting together.
Mark Philippon, you knowRyman's on there too as well,
tons and tons of really smartpeople just getting together and
trying to kind of like build aninterdisciplinary framework of
like how to manage these peopleand like what's the best course
(06:45):
of action and like what is thekind of wouldn't be a clinical
prediction rule, but more solike what are the things that
are important to know whethersomeone's going to do well or
not do well with surgery or notdo surgery.
And the Doha agreement isanother one which is more about
classification.
But essentially a lot of thesestudies Doha, warwick and some
other stuff have just shown that, generally speaking, on exam
you want to have somebody whohas a consistent, provocative
(07:09):
sign of FAI with, like flexionor internal rotation or
adduction or some degree ofcutting and pivoting that mimics
mechanical symptoms.
Right, so they could have likepopping, clicking, catching as
well, but generally speaking ithas to be repeatable.
So that's kind of one thing.
Two is that they want to makesure that MRI findings are
relevant to the current case ofpain.
So they have to have MRIfindings that match the symptoms
(07:32):
they present with, becausethere's a lot of things around,
like groin issues or abdominalhernias or sports hernias or
other things that areoverlapping that maybe you get
an MRI and it shows you have alabral tear, but it doesn't
necessarily, it's notnecessarily causing your pain
right now.
You know 50% of hockey playershave a labral tear.
That's not symptomatic, right?
So just because the sportdemands same thing with baseball
(07:53):
and shoulders.
And then, third piece of many ofthese is that diagnostic
injection is typically veryuseful for these folks to figure
out if we take light again or acortisone injection and we
inject it into the hip joint andyour pain gets better.
That tells us that you knowthese people are probably
getting symptoms from withintheir joint versus, if that does
not happen, whether pain doesnot change at all despite an
injection into their hip.
(08:14):
They might do a lidocaineinjection to like the hip flexor
or the rectus femoris and thentrying to denote whether it's
intra or extra articularreferral, right.
So those three things.
And then typically people whohave mechanical symptoms and
also have the presence of bonychanges, so cam or pincer
lesions.
Those people tend to not dogreat with conservative care
because, yes, you are symptommanaging, yes, you are helping
(08:38):
with some like kinetic chainfactors, yes, you're managing
workload, but you know if therock in your shoe,
metaphorically has gotten so bigand it's stuck that it's
rubbing against your foot everytime you step on it.
Sometimes you know, justreducing that cam lesion or that
pincer lesion is reallyimportant to not have continual
progression of labral damage,along with maybe repairing a
labrum and stuff like that.
So Warwick and Doha, I thinkthis is more about like
diagnosing groin pain and kindof making sure we have the right
terminology for it.
(08:58):
And then there are some reallygreat exercise or journal
articles this is from theJournal of Athletic Training,
but there's been other ones tooas well that essentially are
going through what FAI is, youknow what their symptoms are,
what they tend to have, and thenlike some diagnostic criteria
and things for eval and thenthings for treatment.
So that's kind of my alwaysgo-to bucket is like a review of
the literature on like whatkind of things are available for
(09:20):
agreement consensus statements,randomized controlled trials,
systematic reviews, reviews, bigpicture stuff, um, and then
clinical, you know single coursetrials that are like
double-blinded gold standard forlike treatment is really good
too.
But I know evidence kind of istop of mind for me, um,
different thoughts on that nowI'm pretty much on the same page
with all that stuff yeah, right, and you guys, this was all
(09:40):
open, this was already availablewhen you guys came out of
school, right?
you guys had all these dang Dangand I'm jealous, bro, yeah,
2016.
I forget when the Delhaagreement was, but yeah, so
that's the first thing youshould do is you should um head
to PubMed and you should readthose three articles, but then
also look at a lot of the otherarticles that have notable
(10:03):
authors that I know are in thefield.
So like there's two or threehip surgeons like Dr Kelly, um
Calcivart, um Philippon it'slike a bunch of like hip
surgeons that all they've donetheir whole life is kind of like
hip surgery and like laborrepairs, and then, of course,
pts Ryman, mike Voigt they workwith a lot of hips.
So if they're publishingresearch on things, you know
it's probably gonna be relevantthat you want to keep up with
(10:23):
that, and so you just save theirnames in like a PubMed search
and every once in a while you dolike a one year search and
review about all the articlesthat have come out in the last
you know, whatever year or twoon those authors.
Or you can track the table ofcontents in public journals like
the preservation surgeryjournal or sports health or
things like that, and then justflag any like label type things.
(10:44):
So that would be.
My first step is, you know,maintenance care, I would say,
to try to keep yourself up todate on some new stuff that
comes out.
The second piece is to try tofollow clinicians that are in
the clinic but are also maybehave content, websites and stuff
.
And so Dan always comes to mindwith me is like Dan is a very
smart, very hardworking dude andhe spends half his life with
(11:05):
people who have these problems,so he's actively reading the
research but then he's treatingpeople right for all these types
of issues.
So you know dan has a podcasthere on fai I think it might be
with kevin and stuff, but it'slike 35 minutes of going through
how he diagnoses it, how heinterprets the research, how he
treats it, and then kind of getsinto more of like the not as
clinically or not asevidence-based, uh proven.
(11:26):
That like this is how you treatsomebody who's a football
player, who's going back torunning and cutting and pivoting
and they they're in the sixmonths after the labor repair.
The research sometimes falls offon specific categories for like
advanced strength, conditioning, power, plyometrics.
Return to sport.
So Dan is a really goodresource because he's obviously
gone through this himself, buthe has lots of very relevant,
helpful things.
So there's a there's a handfulof people that I think I have in
(11:46):
like buckets in my mind fordifferent online educators.
So, dan, obviously I sit at thedesk next to you, so it's a
little bit obvious for me to sayhis name, but, like you know,
mike Ryman, mike Voigt, likethose people are working with
these types of surgeons andthese types of people all the
time, and so just have bucketsin your mind of those that are
maybe working with thepopulations that you want.
I feel like you found us fromDuke for champion, but then you
(12:06):
probably have a network ofpeople down there that you
connect with for clinical casesor things that are like common
surgeries, right?
Speaker 1 (12:12):
yeah, I feel like I got a lot of my like mentoring
from one of our like through myresidency program, one of our
like mentors, and I feel likeI've got aside from like you and
then at duke, I feel like I geta lot of my like hip advice
from him and then he worksreally closely with one of like
the surgeons on like some hipresearch.
That's not necessarily for fai,but it's a little bit more for
(12:32):
like adult hip pain.
I guess I think he's doing like, I don't think he's doing hip
replacements, I don't remember.
But, um, he does a lot ofresearch on hips and stuff.
So he gets a lot of his likesupplements, his evidence that
he gets in clinic and like fromtreating people in addition to
like the surgeon side of things.
So he gets both all the time,which I think is really helpful
(12:53):
because you really get to seelike both sides of what the
surgeon sees on the imaging andlike what is eval.
And then he gets his side fromlike PT, from treating a bunch
of them all the time and I feellike I've soaked up a lot of his
knowledge too.
Speaker 2 (13:06):
Yeah, and I didn't have this in the outline, but I
just thought of this is that youknow, I think going to like not
surgical meetings maybe, butlike interdisciplinary meetings
is really, really helpful.
Um, I think a lot of thehospitals in Boston at least I'm
not sure if they do this inother areas, but they'll do like
a once per year or once everyother year kind of like I don't
know multidisciplinarypresentation.
The thing that I hate aboutthese presentations they're all
(13:28):
like the presentations are 20minutes long and they just rip
through like 400 things thatthey have to go through.
But it's a really good way tosee a bunch of different
surgeons or clinicians who arelike treating these people when
doing research.
I think the one around here islike New England Baptist will
always put on like some giantyou know orthopedic kind of
conference and a lot of it is avendor shilling for like buying
products, but you'll have likean hour of lectures, 30 minutes
(13:57):
off an hour of lectures and youknow, get your PT place or
whoever you're with to pay forit and uh, it's a super good way
to hear from surgeons that youknow are in your area that are
literally doing the surgeries onpatients that are probably
coming to you and then you knowyou like wait for the right
moment and you try to, like youknow, have an intelligent
question, smooch a bit and go upafter the thing.
Oh yeah, I worked on the roadthis place, like I met a lot of
the surgeons that champion worksnow through Mike, but then I
met a lot of them also just viabeing at meetings, listening,
trying to ask good questions,emailing, following up, you know
(14:19):
, going to appointments withsome of my patients that were
going to get surgery and justsaying like hey, is it cool if I
sit in and like just talk,touch base with this person?
Um, you get a lot of reallygood networking there and, of
course, they're going to sharewith you things that they think
are really important and you'regoing to learn passively from
all the research that they'rereading, you know.
Speaker 1 (14:34):
Yeah, and I do like sitting out on appointments.
I think that's been reallyhelpful for me, particularly for
the hip, and I think the back,but sitting in and watching what
they do to evaluate and howthey make their clinical
decisions is really helpful tolike see that background.
And it's helpful from aneducational standpoint too for
your patients when they come inand they're wondering, like
should I get surgery, should Inot?
(14:54):
Like they're asking you allthose questions too.
Speaker 2 (14:56):
So having an idea of kind of both sides of like what
your clinical opinion is, butthen also what, having the
knowledge of like what thesurgeon is looking at too, so
you can kind of anticipate whatthey're thinking as well, yeah,
right, and so there's no betterperson to get like anatomy level
, biomechanical level and orevaluation tools from the
surgeon, because those peopleare using those tools to
(15:19):
determine whether they're goingto cut into this person and do a
huge surgery.
So you want to make sure thatyou're using the diagnostic
tools.
Obviously, like treatment wiseand exercise is kind of more our
bag.
But the evaluation that thingsare looking for in imaging,
x-ray, mris that you know Iusually do an in service for the
people at Champion and like wego through some of that surgical
, you know, or imaging basedthings they look at like an
alpha angle and a cam lesionwhat's that look like?
(15:41):
And a lateral center edge angle.
Like it's important for us asPTs to know what these things
are.
Not that I would diagnose thaton imaging I'm not a radiologist
but if somebody comes with animaging finding it has a bunch
of these angles.
You need to know what they meanand what's significant versus
what's not, which ironicallyleads to the next kind of
resources that you know thisbook is a $900.
These two textbooks is $900.
So like I wouldn't go investyourself, um, but a clinic.
(16:02):
You know, if you have a clinicthat is seeing nonstop hip labor
repairs and all sorts of otherinjuries in a sporting
population, you guys should tryto do a bake sale and you should
try to raise money to buy thesetwo textbooks and have them on
your shelf.
Because you know I wasfortunate that, like when this
came out, I was like peak shiftmode and so I was like using the
money from consulting andteaching to reinvest in my book.
(16:24):
So I had these two and I readthem, but like having that book
access to you when a weird funkylabor repair comes in with our
PAO which you've never treatedbefore, like you really want to
know like how these surgeons aredoing these um surgeries and
what they look like.
So you know, not all thesechapters are relevant because
some of them are like whatscalpel to use and like how to
suture you know a hip it's likemaybe that's not the most
(16:44):
important for you, but a lot ofthese things are combination of
PT advice from really goodsurgeons that have working with
them or protocols, but then alsoyou know when they do a label
repair or cam reduction, likewhat are they doing?
Where are they cutting, whereare the port-a-holes goal?
You want to know all that kindof stuff because it matters.
If you have a better command ofthe surgery they're doing,
you're going to be able to makegood decisions.
(17:04):
And also, like, the first threechapters of this book are like
thick, thick anatomy andbiomechanics stuff which, like
if you're working with thesepeople, you really gotta, you
know, do your due diligence toknow about you know, I mean yeah
, definitely, and I think Ipushed this in one of the last
podcasts too.
Speaker 1 (17:18):
But I I feel like I have learned just so much more
by sitting in on a surgery.
Yeah, just watch it, see itlike even if they're doing like
an arthroscopic surgery, you'restill watching them like take
the x-rays in between each, likecut that they're doing and like
they're in their element, sothey're teaching everything that
they're doing.
And then if there's like amedical resident in there, then
(17:38):
they're also teaching themeverything they're doing.
Speaker 2 (17:39):
I feel like you just learned so much yeah, it gives
you a much better appreciationfor you know why people are
sometimes so cranky and arereally going through it.
Two, two things that wereeye-opening for me.
One is that I actually mymother, my mother had shoulder
surgery, a rotator cuff repair,with Dr Ramappa locally in
Boston.
I've treated a hundred ofRamappa's patients but I see
them like for an hour a weekpost-op or two weeks post-op and
(18:01):
they go home.
I don't spend the other 23hours of them being with my own
mother through the entire nightand watching her like struggle
and pain meds and sleeping andbathroom Like.
I really had a much betterperspective on like why people
are really tired and reallycranky and are really having a
tough time and how hard it is,particularly in the first two
weeks of a big surgery, hipwhatever.
It gave me a lot of perspectiveand empathy.
Knowing what's going on on theother side of the kind of
(18:23):
appointment too is to your point, as I watched a lumbar fusion
surgery in grad school and youknow when you watch a lumbar
fusion surgery or an ACL repairor a total hip replacement, it
is not delicate dog, it is not.
It is not like these very likegradual, slow cuts.
It is like Home Depotconstruction.
Sometimes orthopedics is prettygnarly, so you understand why
(18:44):
it's a bit more, uh, invasive.
And then also why somebody'ship or their knee might be
throbbing and killing themimmediately post-op, why you got
to go slow and drugs are okayand ice is a good thing.
You know, like these, thesethings are in place for a reason
and not to always just kind oflisten to like the social media
swing of like never ice, anybodyever.
It's like all right, that isclearly misguided guidance.
Sometimes some post-op cuff orknee repair ice is probably
(19:06):
helpful, because I'd rather doice than shit ton of Viking.
You know, um, I had one more.
Oh right, I mean, yeah, last oneI would say is, uh, academic
people.
So I'm a big fan of clinicianswho are academic teaching, but
they also go out of their way toteach courses.
So, um, I think both areimportant.
I think clinicians who teachcourses and academics doing
research who also teach coursesand maybe do clinic stuff as
(19:28):
well.
Like you need both.
You need the academic point ofview and to kind of understand
the research really well.
Mike is like ridiculous on howmuch research he can process and
synthesize and he runs his ownresearch he's on the doha
agreement or the work I figureit's one but like someone who's
in the trenches, who takes timeout of their busy life and their
family to make a course for youon like all the things they
think about, probably importantto to go about that.
(19:49):
So I took this course veryhelpful, but that I think I view
this a little bit differentlythan someone like Dan, for
example, who's primarily aclinician and happens to read
research and interpret that andapply that.
So, um, I know it can beexpensive for con ed, but I mean
between your own budget andbetween like a course that your
clinic can all kind of takeadvantage of, there's definitely
something to be said about it.
Like you want to take this hipcourse and you split it with
(20:10):
your employer and then your jobto pay back your whatever half
you didn't pay for is to likemake an in-service and present
it to like your coworkers.
Like, if you're not in a clinic, that's open to the idea of
that bro, like finding a clinic,but like that's a very
reasonable thing to do is like,all right, once per month or
once every two months, we'll payfor you to take a course and
then your job is to kind of likedo an in-service for us so that
we can all get better, likethat's a fantastic way to run a
(20:31):
Con Ed clinic along with.
You might just really want tolearn about it.
Maybe it's on sale for ahundred bucks and you want to
buy it yourself and inhale it ona weekend.
You know it can be expensive,though.
Speaker 1 (20:39):
I'm not going to front.
Speaker 2 (20:40):
You know, I know it's expensive.
An $800 textbook is a littlerough.
Speaker 1 (20:43):
Yeah, that's, that's a lot.
Speaker 2 (20:56):
I'm looking at my shelf and there's like a
shoulder textbook with Mike andMike and James Andrews they
wrote that two volumes of thehip preservation one are pretty
good.
There's an ankle, one is a kneedisorders one with Frank noise
who's kind of like one of thegodfathers of like knee rehab or
knee surgery.
So yeah, like each joint hasthese like big, big textbooks
that are probably good for aninvestment to kind of keep your
eye on.
And you know I don't think I'veread them cover to cover but
(21:18):
like I've definitely handled allthe chapters that I think are
most relevant to me.
And then I can't tell you howmany times I've had to go back
and research.
Like I remember the first time Itreated like treating an elite
gymnast with a huge PAO and thesurgeon and I talked for a long
time and he's like, yeah,there's a lot of good research
on like these very lax, fullyskeletally mature adult females
who have this issue and theywant to get back to casual
running and you know, likestrength training, I was like
(21:40):
all right, cool bro.
But like this is like a 17 yearold lead gymnast who has a
scholarship on the line, he'slike yeah, yeah, good luck with
that and I was like awesome.
So I had to read like all, yeah, he was a phenomenal surgeon.
Her surgery went really reallywell.
But like once we got past like24 weeks and it was like past
the oh no phase.
Um, he was more just like, yeah, we're gonna have to progress
based on how you feel, as goodwith strength conditioning, and
(22:01):
as long as she's not gettingworse, we'll just keep cruising
along.
So it's kind of like the wildwest and I was just like reading
those textbooks and trying tounderstand the anatomy as much
as I could.
Yeah, a lot of trial and error.
You know there's no rcts on howto treat an elite gymnast with
a pao.
Speaker 1 (22:13):
You're kind of just like shooting by the hip yeah, I
feel like I don't see very manypaOs and like older kids, I
feel like I see a lot of youngerPAOs, variations of a PAO, and
like kids that aren't fully like, their bones aren't fully
formed yet.
Speaker 2 (22:25):
Yeah, it was a last ditch effort.
Unfortunately, she was not acandidate, for she had no bone
illusions.
She had no cam, no pincer.
Speaker 1 (22:31):
She's just very, very lax, or like dysplasia was at
an all time high but that's whatmade her angles that you're
talking about, I feel like comeinto play a lot like having a
good idea of like what thesurgeon's measuring in there,
because I went through all ofthose like types of measurements
with the surgeon and like putthem all out on like a diagram
and it was really helpful tolike have those like pieces in
mind when you're looking at liketheir x-rays.
Speaker 2 (22:52):
Yeah for sure, and some of those surgical textbooks
like they're so dense with liketwo pages of writing will give
you so much information that youhave to really stop and like
write it out and maybe look atmore stuff.
But like all that stuff camalpha angle, lateral center
energy angle, anterior centerenergy angle, like crossover
sign, how they measure all thosethings is helpful and there's
probably like there's like 50,right, but out of 50, there's
(23:14):
probably 10 that are reallyrelevant and you just want to
have a working knowledge of sothat you can kind of be
conversational.
Maybe if you see them or ifthat radiology report comes
through they, you know they getthe MRI done and they just send
you a screenshot of the findingsbefore they see their surgeon.
You can have a little bit of aoh, this is kind of what it
seems like here and you have abetter kind of head on your
shoulders to know, like wherethis person's coming from before
(23:34):
they see the doctor yeah, andit helps with, like your
justification, I feel like, orthe I, the surgeon's
justification for why they'retotally proceed with surgery.
Speaker 1 (23:42):
Because I feel like I get a lot of like parents and
patients that are like, do wereally need this?
Like yeah, like they're stillkind of like questioning,
especially if they were doinglike a just like therapy before
they decided surgery or not andare they waiting on imaging.
So it helps you kind of likegive them an idea to and be
knowledgeable and like if that'sthe justification, like a lot
of times, like our surgeons willput that in there for their
(24:03):
justification, yeah, especiallylike okay, yeah.
Speaker 2 (24:09):
And I view it the same as like when you do
strength numbers and you'redeclaring someone to run after
an ACL or not.
You need objective numbers ondining, like dynamometer testing
and jump testing and all thatkind of stuff.
Like that's very much like theglue of why we make decisions is
like some of these decisions,especially in sports, are a very
big deal for someone to takesix months off or to go back
earlier to not.
So you do the best you can, but, like you need as much
objective, factual informationto base these things, to make
(24:34):
clinical judgment as possible,and not just like well, you know
, I think we're ready, youquestions like that.
I think that, though, alone isprobably good for those people
to get started and take thatsystemized approach of like
evidence clinicians, surgeons,academics and you can apply that
to any joint or thing you wantto learn about.
So sounds good, cool beans.
Speaker 1 (24:51):
I feel like we could do like a whole separate, like
episode on like treatingdifferent buckets and like how
you approach that with likepeople who have like more bony
overcoverage versus deeperhyperbolo.
Speaker 2 (25:02):
Like overcoverage, undercoverage.
Oh yeah, definitely.
We'll put that for the next oneFAI versus dysplasia, hyper
versus hypo.
I'm down with that.
I just did an internship, Ijust did an in-service on that.
I'm pretty good with that TBDAlright.
Bye everyone.
Speaker 1 (25:19):
Bye.
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