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#2 - Managing FAI syndrome with Dr. Jo Kemp

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In this episode you will learn how to best manage Femoroacetabular impingement (FAI) through exercise rehabilitation and advice/education. We have chatted with hip expert Dr. Joanne Kemp. Jo is a titled APA Sports Physiotherapist and Senior Research Fellow at Latrobe Sport and Exercise Medicine Research Centre. She recently did a brilliant Masterclass for us. You can watch it for free with our 7-day free trial: https://www.physio-network.com/join-masterclass/



SPEAKER_01:

We found that strength in these particular planes of motion, so strength in sort of external and internal rotation, was really not well related to any outcome. So it didn't seem to have any relationship with pain or functional performance or any of those other outcomes, whereas strength in the bigger muscle groups did.

SPEAKER_00:

Femoroacetabular impingement, or FAI, it's a common condition we all see. It's often a tricky one to treat, and there's a little bit of confusion on how we go about it conservatively, particularly how and when to use exercise. So today we've brought you Jo Kemp. Jo is a renowned expert in non-surgical management of FAI. She's a senior research fellow at La Trobe, and she's a titled APA sports physiotherapist with 25 years experience, and she is wonderful at treating hips, particularly FAI. I really enjoyed this episode. I hope you do too. My name is Michael Risk and this is Physio Explained. Thank you for joining us, Jo Kemp. We're going to talk about FAI.

SPEAKER_01:

Thanks very much for having me, Michael. It's great to chat.

SPEAKER_00:

We're going to go straight into it as we do. We were talking off air about rehab for FAI. And two of the things you mentioned were not being long enough and not being dosed enough. If we start with number one, not being long enough, could you expand on that for us?

SPEAKER_01:

Yeah, certainly. So I think that often both physios and their patients are really impatient to see results. We want to get results quickly. And if we don't sort of see significant improvements or see the condition resolve or get better after a few weeks, we tend to think, well, it hasn't worked and we need to move on and refer on to an orthopaedic surgeon or, you know, refer for an injection or, you know, the more invasive and expensive treatments. And I think that that can be a mistake because we recently, earlier this year in BJSM, published a systematic review. And one of the findings of our systematic review was that the rehab programs that went for at least three months tended to have better outcomes than those that were shorter duration. And most of the studies in our review were six weeks. But it it seems as though you really need to persist with these rehab programs for at least three months for them to be most effective. And I think that that makes sense if we consider sort of muscle strengthening principles and physiology, that it's unlikely that you're going to see major changes in three or four or five weeks. And also it can take that long to get the patients to buy into the exercise program and to really become adherent with the program and do enough of the program for it to be effective as well. So I think that our expectations for ourselves and our patients are often not right in that we want these quick fixes. And I think as long as people know that at the outset, that when you first see them, that you it's going to be three months before we really see significant change. We should be seeing improvements over that time, but we're not going to see really significant change for at least three months. Then people know what they're in for and they don't get impatient and then race off sooner than they probably should to consider those more invasive and more expensive interventions like surgery and injections and those sorts of things. So, yeah, I think it's just really important that we look at sticking with our rehab programs for that long. And three months is a good sort of nice round figure that seems to work for most people.

SPEAKER_00:

That's really interesting that a lot of the studies in the SR were six weeks. What was the difference between the six weeks and the three months? Was it quite large?

SPEAKER_01:

Yeah, look, so it was a reasonable difference. I think we have to qualify this by saying that the studies were all, so there were studies that compared sort of the physio treatment that they were looking at compared to some sort of sham or control treatment. But the studies were all pilot RCT. So I think we have to qualify that statement by saying that they were pilot RCTs. And so these things do need to be confirmed in larger RCTs. And we actually have a large RCT that's underway at the moment that we've just finished recruiting into where we actually treat people for six months. And we've got a bit over 150 people into the clinical trial. So we're hoping to have the results of that sort of out in about a year's time. And I think that will give us a more definitive answer. But there was a difference. The differences were significant in the studies that went for three months and they weren't in studies that went for six weeks. There were also some differences in the type of treatments and exercises that were in the study. So, the longer studies also had a larger strengthening component to them, whereas the shorter studies tended to have more sort of what we might call motor control, activation type exercises. And so, it might not just be the three months, it could also be the type of exercises that are in the program that made them more effective as well.

SPEAKER_00:

That's really interesting. I think we'll get on to number two, which is the dosage. But I want to come back to that point. The differences in the more motor control smaller muscles versus, say, the larger muscle groups, which you just touched on. Talk to me about the dosage as well, because that was something you brought up.

SPEAKER_01:

Yeah, so look, I think that... Physios, you know, we consider exercise to be our bread and butter and exercise, the prescription of exercise is something I think that all physios would consider to be the number one tool in their toolbox, particularly in the musculoskeletal and sports domain. And I think that we are really good at coming up with creative exercises, different exercises, exercises to suit the patients, but perhaps an area where we haven't been so good at in the past is considering the dose of the exercise. So the way I like to explain it to patients is that if you, if we know that you need to take, you know, 500 milligrams or 1,000 milligrams of a particular medication for it to be effective to reduce pain or inflammation or whatever, you know, blood pressure or whatever the medication's for, if it says you should be taking 500 milligrams but you only take 100 milligrams, then of course it's not going to work and we all know that and no one would ever do that. You would never take, you know, a fifth of the dose of what the prescribed dose, the recommended dose or the effective dose is. But I think in exercise, we probably don't do that. And so I think as physios that we have to really think hard about what's this exercise trying to achieve? Are we actually trying to achieve muscle strength and muscle hypertrophy? Are we trying to achieve strength endurance? And that we can use some of our strength and conditioning principles to achieve that aim. And so one of the things, we recently published a consensus paper in BJSN that looked at what physio treatments for hip pain should comprise or what they should look like. And One of the key recommendations that, you know, 40 experts from all over the world came to was that we have to get really good as clinicians at getting the dosage right. But also in our clinical trials, we also need to get a lot better at reporting the dosage. So that's something that lacks in a lot of the studies, not just around hip pain, but around other musculoskeletal conditions is the exact dosage is not reported. So, you know, the number of sets, the number of repetitions, the duration of each repetition in time, the duration of rest is, You know, the mode of delivery, are we looking, you know, the eccentric versus the concentric components, the isometric components. So we need to really think about those principles of strength and conditioning and really try and incorporate them into our rehab programs and be very specific with what we tell our patients. So don't just teach them how to do the exercise, but be really targeted and specific in the dose that you give them to do as well.

SPEAKER_00:

There's some good distinctions there. How do you approach the dosage? Is there anything in the research that suggests one dosage better than another? Or from your clinical experience, are you someone who goes, say, heavier, less reps or lighter and more reps? Or is that just a complete clinical decision with the patient in front of you?

SPEAKER_01:

Such a good question. So if we talk about the evidence first, there isn't good evidence in hip pain on what the best dose is. So we don't actually have that evidence in the hip pain space at the moment. But I thought we do have evidence on how these patients are impaired and we know that they do have strength impairments in their muscle strength, particularly in their hip muscles and also in their trunk muscles. And so if we think about impairments in strength, we're trying to improve strength and target strength. So generally I would target strength for a dosage for strength, so strength hypertrophy. So in a lot of cases, I will give exercises, particularly around the hip, that are heavier exercises, fewer reps. And so often it's three sets of six or three sets of eight reps at a fairly heavy resistance, depending on the exercise, and asking the patients to do it two to three times a week. And so for patients, I actually really like that because it's Fewer reps means it's easier and quicker to do. Less times a week means it's easier and quicker to do. And that's sort of when you think of strength and conditioning where you're most likely to get the best strength effect. So for the hip muscles, very much a strength, muscle strength, strength hypertrophy approach. Thinking about trunk strength and sort of more functional strength, I might take more a strength endurance approach. So we may be looking more at longer periods. more repetitions, longer hold times for some of the exercises. But it does depend on the exercise and the muscle group that we're trying to target. But it is very much a strength dose for muscle sort of strength and hypertrophy. The other thing about the heavier weight for your repetitions is you also don't need to move through as much, a bigger range of motion to get the effect. And one of the things that we seem to see in patients with hip pain is when they go through certain movements, And big ranges of motion, it can be really irritable. If they're in a really, in a flare of their pain or if they're in a real sort of inflammatory side of it phase, going through big ranges of motion can really irritate their pain. And so dosing heavier means that you can often get a good strength effect without going initially, without going into that big range. And you can save the bigger ranges of motion for them as their pain settles and they get stronger as you progress them.

SPEAKER_00:

This is great and we're getting to the juicy part because I spoke to you off air and I was saying to you I've been out of practice for a year or so and that the last thing I remember was like the rotator cuff of the hip and learning some really fine motor slash rotation movements and what you were saying is that you would prefer to focus on say adductors, extensors, hip flexors, stronger movements without as much rotation. Could you speak to that?

SPEAKER_01:

Yeah, there's a few different reasons for that. And look, I will be the first to say that 10 years ago, I very much practiced in that rotator cuff of the hip space. But something I observed clinically is that when patients actually do a lot of rotation, when they have hip pain, it really hurts, it flares up their pain. And so I it was really hard to persuade them to do these exercises when they had to twist their hip in different directions, you know, twisting your foot in and out and dropping your knee in and out and putting a lot of rotation through the hip. It tended to exacerbate their pain. So that was the first thing. The second thing that really changed my practice was when we actually did– our research and we found that strength in these particular planes of motion, so strength in sort of external and internal rotation, was really not well related to any outcome. So it didn't seem to have any relationship with pain or functional performance or any of those other outcomes, whereas strength in the bigger muscle groups did. So, you know, when we looked at our data that strength in hip adduction was the number one strength that correlated to outcomes. So the stronger you were in your hip adapters, the less pain you had, the better quality of life you had, the more able you were, you know, the more you were able to do things like squat up and down and hop and jump and those sorts of things. So, but the other muscle, other big muscle groups were very important as well. And so I think that was a real revelation to me that actually, it's the big muscle groups that seem to be more important in improving outcomes in these patients and the small muscle groups. And I think we can also justify that in, if you think about a muscle like quadratus femoris, for example, which is traditionally been considered to be, you know, an external rotator and one of the, primary, you know, the primary rotator cuff muscles. It's not to say that that muscle is not important, but when you actually look at the moment at how, at the way that that muscle works, it works, it actually works more strongly into as an adapter than an external rotator. And it also works as an extensor. So, so if you think about, We're retraining these. We're not retraining muscles. We're retraining movement. So we're trying to improve hip adduction strength. So we're actually strengthening those muscles like quadratus femoris in doing that. You don't just have to strengthen it in external rotation. We're probably also getting that strength effect in that mechanism through our, you know, fairly... straightforward standard adduction or extension strengthening exercises. So I think that was sort of the really important thing for me was looking at the research and actually saying, well, my hypothesis that the rotators were going to be important was disproven. And then, you know, we can find a good rationale for that. And it also doesn't hurt patients as much. They don't get pain doing that exercise like they do in the rotation exercises as well.

SPEAKER_00:

That sounds like a similar theme that we're learning across all areas of the body is that when you do harder, more global exercises, what we would have considered stabilizers are also being trained and worked hard as well. And Jo, I wanted to... What would be one or two of your education pearls that you give to a patient in front of you?

SPEAKER_01:

I think pain's a really important thing to address. And there's a couple of different things around pain that are important. So the first thing is that people with hip pain do get flares of pain. It does flare up. And if the flare of pain is not manageable, don't be scared to get the GP involved and to look at getting some analgesia or anti-inflammatory medication in the short term to help settle that pain and encourage patients to do that. A lot of people, you know, I don't like to take painkillers, I don't like to take drugs, but, you know, I think if you convince them that in the short term it could be helpful, then don't be frightened to get help to settle pain down. You shouldn't have to solve that problem yourself. We should be working in our multidisciplinary teams. But the other thing is that it is actually very normal and safe to exercise with a bit of pain. So We're now learning in the hip that the relationship between structure, so things like label tears, cam morphology and pain is really, really poor. And Josh Heery has done some really, really good work in this space recently that he's published that shows that. So having some pain while you exercise or do activity does not mean you're causing more structural damage and it's safe to do that. So it's actually safe to do exercise with pain an acceptable level of pain. You don't want extreme pain, but as long as it's acceptable to the patient, you know, two or three out of 10, it's actually safe to exercise with pain and it's normal to get pain, particularly when you're progressing exercises. When you're doing something new, you may get a little bit of pain and then that's okay and that that's safe. And as long as it settles down within 24 hours and stays in that two to three out of 10 increase, then that's perfectly okay and that they're not going to do more damage. And that is not just for our strengthening kind of physio, lead rehab exercises, but also general exercise as well, that when you're going for a run or a walk and you have a bit of soreness and pain, it doesn't mean you're causing damage and you shouldn't stop and lie on the couch to try and address that.

SPEAKER_00:

That's amazing. I've got some key takeaways here, Jo. I love the three months thing. I think how you pre-frame that and educate that right off the bat and probably continue to do that. The Panadol analogy I thought was a really good one that we could all use soon. If you're taking the wrong dosage, it's not going to work. We could use that for exercise. And I like the hip and trunk as well, is not to forget the trunk. So some real pearls there. Thank you so much for your time, Jo, and thank you for joining us on PhysioExplain. It's

SPEAKER_01:

a pleasure, Michael. Thanks very much for having me.