Femoroacetabular Impingement with Mike Reiman - Episode 17

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On this episode of the sports physical therapy podcast, I'm joined by Mike Raymond.
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Mike's an associate professor at duke university and someone that I know I've learned a lot from over the years through his publications and social media.
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And this episode, we're gonna be talking about FAI or femoral, acetabular, impingement, and we're going over things that you need to understand the diagnosis non-operative treatment and surgical procedure.
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Hey Mike, welcome to the podcast.
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How's everything going?
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Uh, it's awesome to be here.
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Thanks for inviting.
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Yeah,
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Yeah, no, my pleasure.
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Um, you know, Mike and I were just talking about this on, you know, the pre-recording of this when we, when we just hopped on zoom.
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But, you know, I, I, I was super complimentary to Mike about how great he's been doing on social media and his online courses that he's been launching.
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It's just really great to see, uh, an educator, a clinician in a mind like yours, Mike, you know, branching out and, and getting online to, to give more exposure to all the great things you're doing.
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So thanks a lot.
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no, I, I, I appreciate it.
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Um, definitely a, a learning game for me.
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So it's, um, obviously being a little bit older.
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I didn't grow up with social media.
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And so it's like, I'm still trying to figure out the game, but I, I, I do appreciate the, uh, the desirable difficulties of like, trying to figure out how, how things work.
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So.
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Which is great.
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And I actually, I think it's good that you don't know the game because what you're doing is you're approaching it from a real humble and honest background and just trying to share your experience and,
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Yeah.
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Yeah, no, it's, um, you know, I like to, uh, so with my students, I give a lot of what I call dad talks.
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And so some I've been trying to post some of those types of things and, and also indirectly is, um, you know, I have two kids that are, you know, just above teenager and.
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So it's kind of more indirectly to, uh, maybe give them advice cuz if I gave it to'em directly, they probably wouldn't listen to it.
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So maybe if I post it, they'll they'll look at it and maybe it'll resonate a little bit.
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that's awesome.
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That could be the best social media strategy that I've ever heard right there.
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I like that.
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uh, I'm not sure it's working, but it's, it's a strategy.
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Well, I also want to give you a huge compliment here too, because, and I didn't tell'em this beforehand, so this is new, but, um, I, so we get tons of students from around the country at champion and we get a lot of great duke students.
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Um, but.
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Every student raves about you as an instructor, Mike.
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Um, and I, I just wanted to make sure you knew that because you know, sometimes you, sometimes you think you're doing a great job, but you don't know that, but, but we ask the students right.
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When they come through, like, you know, how's your school, how's your program.
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How's, how's your instructors.
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Right.
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And they all rave about you and, and we have a ton of great duke students, and that definitely reflects on your effort.
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So I just wanted to give you a big compliment on that too.
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that, uh, that's awesome to hear it's um, I definitely appreciate that, cuz I mean you're right.
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Is sometimes you're not sure you, you, you know, you look at.
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Of the yearly reviews and, and it's things like, um, I mean, it's, sometimes it's funny stuff like, you know, it's like he doesn't dress very well or, you know, he is you know, he is wearing, he's wearing a brown belt with black shoes and just, um, stuff like that.
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And it's like, okay, how, I mean, is that really important?
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So, but, um, no, and it's, uh, I definitely appreciate that.
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And, um, you know, to be honest too, it's like, we just get a lot of good, you know, really good students.
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And so.
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Um, it's that's that's great to hear.
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Thanks.
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Thanks for sharing.
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that.
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Yeah, no, my pleasure.
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Um, you know, I, I, I just, you know, I, I think it's nice for you to know those sort of things, but, um, so one big area that I wanted to hit on the podcast that we even talk about here is, is, you know, Mike has a special interest in hip, um, uh, pathologies, right?
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So I wanted to make sure we got Mike on here to talk about, uh, hip things.
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Um, and one specific thing is I really wanted to talk about was the diagnosis of OFI or Famor tabular impingement, because to me, I mean, you know, We're now old enough, right.
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Mike, where we, we can see arcs in, in, in sports medicine and orthopedics, and we can see trends and stuff like that.
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But for me, likeI has really blown up recently, like the last, probably five to 10 years, but even more so the last five.
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Um, and, and I remember early in my career, several people that I reflect on and I think, oh, that Wasi and I totally missed it.
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We treated as groin for six weeks and nothing happened and you know, we missed it.
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Right.
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So, um, why, why don't we start there and, and why don't you tell us a little bit about your experience with, with, you know, the hip and your education with the hip and, and a little bit of the history
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No.
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So it's, so history has actually been for a long time.
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I mean, actually, if you look, you know, well, cuz I did.
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Part of this for my PhD.
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So this is the reason I know this is, but if you look back on the history, This kind of general concept has been reported as, as early as like the 1930s, but nobody like it just is one of those things that kind of sat for a while I think.
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And then, um, where it really became famous, I guess, so to speak is, uh, in 2003, Ronald GS, um, from Germany, published a paper and said, Hey, you know, I'm seeing a lot of this.
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And so he, he, he actually described what's called cam morphology.
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where the form we had is larger than whatever we think is normal.
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And that's a whole other issue too is, but, and so we described that and then he kind of extrapolated, well, that's why these people are getting label tears.
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That's why they're getting CVA.
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That's why they're getting pain.
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And, and this was a, a paper that sent was, Hey, here's what I'm seeing in surgery.
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And then, so then after that, it just exploded.
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And, and I always kind of looking at liking it back to, well, like, like your, one of your areas of shoulder, you know, near, I mean, that's essentially how a subro impingement kind of started to, to my understanding is near described, Hey, here's what I'm seeing.
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And then that, you know, that paper got, you know, I mean, has like, like almost a thousand citations.
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And so, and so it was.
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So nice thing is that, Hey, here's what I'm seeing.
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Here's what I think.
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But then like, then, then the rates exploded.
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And so like, we've kind of all already jumped ahead of like basic science saying, okay, well that's what you're seeing, but you know, are people truly impinging and are they, are they tearing their labor on?
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And so, you know, what's, what's interesting is that paper is, is decided more than any other paper related Toi.
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And they did this, you know, a couple years ago, they did.
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Um, paper on like the 50 most cited papers on FAI syndrome.
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That was the most cited one.
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And outta the top 50, like only 4% of them were basic science studies.
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And, and so like I've written a couple pieces on this and a couple with one of my PhD supervisor or couple both of my PhD supervisors and just, and who, one of'em is a surgeon.
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And essentially, like, I think I get kind of this rap that I'm antis surgery, which.
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You know, where, where I'm housed is actually an orthopedic surgery and I'm not antis surgery, I'm just anti overutilization or what, you know, just maybe slowing down a little bit and figuring out who are the best surgical candidates.
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And so,
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That's a great way of saying it.
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yeah, it's crazy.
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And so, but where it personally happened for me is.
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Like I was a clinician for a long time.
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And in, in about 2003, I was a clinician and, and I saw that paper and, um, and I had a patient, I mean, same thing that you, you know, I'd probably missed a ton of them.
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And, and I had this patient that I thought had hip and Benjamin.
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Um, and so Beth, you know, I was in Wichita, Kansas, and at that time there was no surgeons, you know, close.
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I mean the nearest one was Dr.
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Burr in Nashville, Tennessee, which was like nine hours away.
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And so.
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Right.
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So my whole decision is like, do I send this patient nine hours away to, to do the surgery?
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Because quite honestly, my was probably not very good.
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So long story short, as I ended up sending them and he saw him, he said, no, this is you.
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You're not a surgical candidate.
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So they come back, thank God.
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They came back to me versus like going to somebody else.
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And so, like, I just had to figure it out and kind of an over long period of time as they eventually got into academia.
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Got into, you know, and that was the whole thing, you know, there's a lot of things like, I'm sure you have stories of these patients that just sit with you.
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And, and like that patient sat with me for a long time in my mind.
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And just like, so then when I finally had the opportunity to do PhDs, like that's, you know, I wanna try to figure this out, you know, how do we diagnose these people?
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So that's, that's kind of the history and kind of the, where it helped me or where it reflects with me person.
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And I love that too, because I think there's a, there's a trend I'm seeing with a lot of these interviews on this podcast is that a lot of times people have sought to become an expert at something or a niche at one certain thing from a, a personal experience, just like you, you said right there, there's almost like a catalyst that said, okay, I'm gonna dive in deep on the hip and do my PhD on the hip because I miss that.
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And it's, and it's eaten at me a little bit.
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And, and you know, that, that tells you a lot.
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You know, you know, your personality and, and, you know, the service based industry that we're in.
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We, we wanna always succeed for our patients.
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So, um, that that's really cool to hear.
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Um, I know for the shoulder, I, I feel like our understanding of the shoulder exploded with our thoroscopy.
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Right when we could actually get into the joint a lot easier, a lot faster.
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Um, is that essentially what happened with FAI too?
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Do you think once we started doing hip scopes and we started seeing this a little bit more and, and probably being able to treat it a little bit better.
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Do, do you think that was part of the, the history of why FAI has really been exploding recently, too?
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Yeah.
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I mean, I, I do think that I think, um, you know, kind of you, I won't give the whole history, but if you kinda look at story, definitely increased after 2003, and most people were doing open at that time.
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And then.
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You know, probably, you know, a few years later, you know, they started dabbling with arthroscopy and, you know, as you know, it's like, that's more challenging, especially in hip, cuz it takes a lot of force to distract.
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But, and then from, you know, like 2007 to 2013, so about a six year period, like the rate of surgery had increased like over 2000%.
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Like it, it just completely exploded and even it, it was higher than any other.
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Now there's probably a lot of reasons for that, right?
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I mean, it's probably, you know, the fact that, you know, now we're doing scopes now.
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I mean, cuz probably, and the other thing is you, okay, now we have an idea what this pathology is and, and how to diagnose it.
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And then also patients at about that same time, their studies showing that patients had what we think is hip impingement for, you know, almost two or three years.
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And it's seen multiple providers.
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Before they actually were truly diagnosed.
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And so patients are frustrated.
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They've been to rehab a couple times and, and weren't getting better.
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And so, yeah, I do.
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I do think the arthroscopy and the other thing is like, if you look at the rate that rate that's increased, a lot of it is new surgeons as well.
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So like 600% of that growth was, was new surgeons.
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So you get new surgeons in there, you know?
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And so you just get more people.
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Doing that.
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And as you know, it's a, it's a learning curve with, with doing arthroscopy versus well, any anything's a learning curve, but you know, arthroscopy is definitely a challenge.
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And, and so now you've got a bunch of newer people that are kind of learning it.
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So, I mean, it's, it's can be a challenge.
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Yeah.
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I mean, I, I think the first wave of, of surgeons that were specialists INI, right?
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Like the, uh, you know, the birds, the Philippines, the Kelly's, you know, they, I, those first wave.
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I, I, I feel like I even heard a story about Dr.
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Bird once.
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So, you know, take this, this is a secondhand type thing, but where it wasn't even like he wasn't even trying to specialize in the hip.
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It's just something that evolved.
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Right.
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You know, probably like us as rehab clinicians.
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Um, but you know, those first wave of people, like you said, you, you, you had to send people to a few people around the country.
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Um, and then, and then it became a hot topic and it became something that people actually wanted to specialize.
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In as a resident.
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So they wanted to go do a fellowship in, in hip arthroscopy.
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Um, so yeah, I mean, any, anytime, anytime you, uh, you add more hammers, they want to hit nails, right?
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Right.
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and to, to put that analogy together, there's way more hammers out there.
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No.
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Yeah, there is.
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And, and no, you're right.
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Like, I, I don't know a story, but I assume, I mean, I, I can definitely see that happening, you know, it's, from the standpoint of, I mean, there are studies showing, I mean, it's like anything, right.
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There are studies showing that, you know, the more experienced surgeons have less complications and, and those types of things.
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And so, um, yeah, probably was out of necessity and, and, um, yeah, I mean, I'm sure that's probably how it happened.
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It's it is just it's.
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It's funny to see, see that over time, but you know, now we're seeing some great clinicians that are being trained by the best, and they're going all around the country.
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Like we have a couple, you know, local ones here that were trained by some of the best ones.
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And it's really neat to see.
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Um, but you know, as, as the diagnosis is becoming more common, you know, I think surgeries are being, you know, being, you know, done more often as well.
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So surgeries are becoming more often.
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So, um, why let's shift gears and talk a little bit about the surgery a little bit here and, and why don't we start with this?
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Like, if somebody is completely new Toi, why don't you give'em a brief.
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Rundown of what the surgery is.
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You mentioned cam lesions before.
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Um, there's also pincher lesions.
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I'd just love to hear a couple of, a couple of like, uh, you know, of your, your thoughts on that for the person that's completely new to this topic.
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And then obviously we'll, we'll, we'll talk about how the surgery goes and the outcomes and stuff like that, but why don't you start with that?
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Yeah.
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So, you know, the, the general concept is, you know, you have an impingement.
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And so either the former head is larger than it, than what we consider to be normal and, or the acid album over overlaps or covers.
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The Foor head.
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So as the patient goes into, you know, hip flex, so flexion abduction in terms just any type of motion probably involving flex, the thought is you get this mechanical button of the Foor, head against the rim, and then, you know, kind of between there is a lab and obviously you have, you know, thisno and all that type of stuff as well.
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And so the, the premise is that if you have a, for forehead that is larger and.
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We know from studies that that happens as a normal adaptation to loading that if it's larger than normal, that it will butt up against the rim.
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And so the theory from a surgical standpoint is, well, if there's a mechanical equipment, why not correct the equipment.
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And so they'll go in and they'll, they'll.
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They'll take the for more ahead and they'll make it more round, more spherical versus, you know, sometimes there'll be like this bony osification on where it's supposed to be going down into con cavity or it's just larger than normal.
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So those will make it more round.
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And so the theory is okay now it's, now it's more likely to go through a full range of motion without hitting up against the rim.
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And so that's the kind of the cam side.
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So cm, the pier side is the.
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They has to have'em over, over extends over the form head too far.
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And so then in that case, what they have to do, I mean, it's a little bit more complicated there because if they have a normal labrum, they have to kind of shave the, they have to kind of like cut the lab'em off, you know, kind of lie it down, shave the bone back off, then take a labrum and then sew it back on.
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And so just to try to, so essentially both aspects are to try to get more clearance.
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So when they go into flex in these different motions that it's not budding up against.
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And, uh, the, the issue is that how much is too much.
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And, and the other thing is, well, when are people impinging?
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And so, like, we have some studies showing that people are impinging up 40 degrees of ction, but they, you know, they don't have pain till 90 degrees.
00:17:18.424 --> 00:17:21.725
So, I mean, like everything it's complicated, so.
00:17:22.460 --> 00:17:31.579
So do do, do you think some people are genetically predisposes that maybe they have just a different morphology of, of their, their joint, uh, versus, you know, loading?
00:17:31.639 --> 00:17:45.439
Uh, because I will say as a parent, um, coming into the youth sport era of today, and I don't know how it was, it sounds like your kids were, you are just getting out of it, but holy smokes, we are doing way too much with our kids, but up here in new.
00:17:46.224 --> 00:17:55.194
The, the ice hockey is, you know, a big one OB obviously with, with hip pathology, but these kids are skating year round, uh, before they're even 10 years old.
00:17:55.464 --> 00:17:58.105
It's it's it's year round it's it's mind blowing to me.
00:17:58.105 --> 00:18:06.325
And, and I keep saying to everybody at champion, we have to stop specializing in baseball and start specializing in hockey because in 10 years, all these people are gonna be on our tables.
00:18:06.325 --> 00:18:10.884
But, um, you know, I, how much is it genetically there versus loading.
00:18:11.125 --> 00:18:14.454
And what are your thoughts on, on, on the future of this with.
00:18:15.014 --> 00:18:16.875
All these kids skating all year
00:18:17.809 --> 00:18:17.990
Yeah.
00:18:17.990 --> 00:18:19.099
That's oh man.
00:18:19.105 --> 00:18:20.909
That's not, that's a huge question.
00:18:21.289 --> 00:18:38.029
Um, so, so I, I mean, I, I, I'll only mention like what I know and then maybe kind of give some of my thoughts is so number one, hip pathology and research is probably 10 to 15 years behind the shoulder and, and the knee.
00:18:38.569 --> 00:18:49.129
And it's just, I mean, it's just a new, the newer kid on the block that said is we do have studies that show and they're mostly European studies that show that what happens.
00:18:49.670 --> 00:18:54.650
You know, so the growth plate is like right between the Foor, neck and the, the start of the Foor head.
00:18:55.220 --> 00:19:04.309
And so kind of towards the top of the forehead, what we do know is it does seem that as you load in, somebody has open growth plates.
00:19:04.670 --> 00:19:06.379
What can happen is that epiphysis?
00:19:06.384 --> 00:19:12.799
So that, that top part of the Foor head, the most proximal portion can actually shift and it'll shift.
00:19:12.799 --> 00:19:17.359
And it'll kind of create this, what we are now calling a cam type of thing.
00:19:17.359 --> 00:19:17.930
And so.
00:19:18.140 --> 00:19:18.470
Wow.
00:19:18.799 --> 00:19:22.039
So that is, you know, kind of Wolf's law type type of thing.
00:19:22.039 --> 00:19:32.930
And then the thought is, well, and there are a couple studies, so there's some studies that suggest this and there's some studies that don't, but that the more you loaded it, the more likely it is to, to ship.
00:19:32.930 --> 00:19:38.900
So almost, you know, kind of perhaps similar to like Crocketts type of stuff with, with torsion in
00:19:38.944 --> 00:19:42.904
I was just thinking that, yeah, it, it, it's crazy the parallels between the shoulder and the hip.
00:19:42.904 --> 00:19:43.954
I mean, which makes sense, right?
00:19:43.954 --> 00:19:45.214
Why wouldn't it be the same?
00:19:45.244 --> 00:19:46.115
The same, but yeah.
00:19:46.595 --> 00:19:47.224
No, it is.
00:19:47.224 --> 00:19:48.785
And so that's, that's kinda what frustrates me.
00:19:48.785 --> 00:19:51.875
Mike is like, we we've already learned some things in the shoulder.
00:19:51.875 --> 00:19:55.085
Like, why aren't we not following that through in the hip, so,
00:19:55.174 --> 00:19:55.684
I can't.
00:19:55.714 --> 00:20:04.585
So you guys are then, so, so we're now in the phase of impingement, isn't real, you know, that's, that's, what's happening in the shoulder and I, I can't wait for these young clinicians.
00:20:04.805 --> 00:20:08.884
To see these people that they ignore the impingement on that go to rotator cuff tears.
00:20:08.884 --> 00:20:09.095
Right.
00:20:09.095 --> 00:20:14.825
Which was just published last month, showing that rotator cuff, uh, tears do progress and you shouldn't just ignore them.
00:20:15.184 --> 00:20:19.954
Um, so yeah, I mean, I, I, I mean, you know, we we've, we started dealing with like, is impingement normal.
00:20:20.744 --> 00:20:21.105
Right.
00:20:21.105 --> 00:20:23.115
Ver and of course impingement, no worry.
00:20:23.115 --> 00:20:23.265
Right.
00:20:23.265 --> 00:20:27.615
I'm sure with the hip that the, the, the joint articulates, right?
00:20:27.615 --> 00:20:39.345
So at some range of motion, there's some impingement, but if you load that or if you've developed your OSUs formation differently, like you, like you just alluded to, then that, that impingement becomes.
00:20:39.615 --> 00:20:43.365
You know, potentially leading to more stress, which then becomes pathological.
00:20:43.484 --> 00:20:48.525
I just think it's so, uh, you know, shortsighted to, to say impingement doesn't matter.
00:20:48.525 --> 00:20:51.434
And it's funny to see the parallel happening at the hip right now.
00:20:51.704 --> 00:20:52.335
So, sorry.
00:20:52.339 --> 00:20:53.595
That was like a mini rant there.
00:20:53.595 --> 00:20:54.194
I apologize.
00:20:54.194 --> 00:20:54.345
But
00:20:55.029 --> 00:20:55.750
No.
00:20:55.779 --> 00:20:59.829
Well, so no, I have the same personal rant to myself.
00:20:59.859 --> 00:21:02.619
I mean, it's like, here's where I think it.
00:21:02.960 --> 00:21:06.200
I mean, the short answer is like, I, I don't know, to be honest.
00:21:06.200 --> 00:21:14.539
And so, and, but what I think is, and so, and so this is where, you know, trying to do some research on this.
00:21:14.660 --> 00:21:22.220
Like we did a study a long time ago and we found these people within Benjamin and, and we found that they didn't all have the same characteristics.
00:21:22.250 --> 00:21:22.549
So.
00:21:23.254 --> 00:21:37.325
Um, so another colleague of mine is, is doing some stuff in the low back and, and doing what's called pheno typing, which is kind of getting into genetics and is also kind of getting into like, what I personally think is, I think you have patients that have characteristics.
00:21:37.325 --> 00:21:40.714
I think you have patients that are primarily impingement type patients.
00:21:40.714 --> 00:21:43.144
I think you have patients that have maybe more laxity.
00:21:43.565 --> 00:21:48.035
I think you have patients that, you know, in combination of more laxity and have been loading a lot.
00:21:48.035 --> 00:21:48.305
Right.
00:21:48.305 --> 00:21:48.575
And so.
00:21:49.369 --> 00:21:52.910
You know, like with a shoulder, I mean, like, I, we were going over listening to class the other day.
00:21:52.970 --> 00:21:55.670
Like I showed, like I have 90 degrees of extra rotation.
00:21:55.670 --> 00:21:56.839
Cause I didn't play baseball.
00:21:57.500 --> 00:22:00.680
We had a kid that played baseball and had extra rotation and they had GERD.
00:22:00.680 --> 00:22:04.849
And like, I know you guys talk about this at CSM every year is like, is GERD a bad thing or is
00:22:04.924 --> 00:22:05.194
right.
00:22:05.960 --> 00:22:07.579
normal adaptation type thing?
00:22:07.579 --> 00:22:10.549
And so I think, I think.
00:22:11.420 --> 00:22:14.000
Broadly saying that, okay, this is bad.
00:22:14.519 --> 00:22:15.410
It is.
00:22:15.410 --> 00:22:18.559
You gotta be careful about that because like, what are that patient's characteristic?
00:22:18.619 --> 00:22:19.700
What is their makeup?
00:22:20.089 --> 00:22:21.230
What is their range of motion?
00:22:21.259 --> 00:22:28.490
You know, what is IR versus ER, you know, like that in the hip seems to be a thing of as far as predictive of torsion in the hip.
00:22:28.490 --> 00:22:28.940
So
00:22:30.184 --> 00:22:30.276
right, right.
00:22:30.740 --> 00:22:33.559
what I would like to eventually get to is, is kind of looking.
00:22:34.384 --> 00:22:42.754
Characteristics of patients and, and the patient comes in and says, okay, well, this seems to be like an impingement type of a patient, or this seems to be more of a displays type of a patient.
00:22:43.325 --> 00:22:49.654
And then kind of having an idea well, from the studies that we know, okay, their, their prognosis tends to be this.
00:22:49.775 --> 00:22:52.115
And so, but we're, we're a long ways from that.
00:22:52.119 --> 00:22:52.285
So.
00:22:52.490 --> 00:22:52.879
Yeah.
00:22:53.119 --> 00:22:54.289
And just like everything else.
00:22:54.289 --> 00:22:54.500
Right.
00:22:54.500 --> 00:22:59.480
I, so, you know, I was at a O S SM like big annual meeting with the sports medicine doctors recently.
00:22:59.809 --> 00:23:10.519
And, you know, two things that I thought were really neat to see the doctor's opinions involved on was, uh, internal bracing for Tommy John and the elbow, and then some similar type things for ACL in the knee.
00:23:10.789 --> 00:23:11.119
Right.
00:23:11.119 --> 00:23:18.019
And, you know, does the ACL regenerate, you know, are there ways to repair it versus reconstruct it and it, and it was interesting to see these discussions.
00:23:18.410 --> 00:23:23.750
And I think the answer came down to is, um, maybe in the right person at the right time.
00:23:24.019 --> 00:23:35.240
And I, and I think this would've come down to a very, you know, we, as something new comes out and we just slap it on everything versus, you know, finding who is like the strict candidate for the best things.
00:23:35.299 --> 00:23:35.599
Right.
00:23:35.599 --> 00:23:37.940
And, and we see this over time all the time.
00:23:37.940 --> 00:23:38.089
Right.
00:23:38.089 --> 00:23:40.430
We were repairing slaps in the shoulder on everybody.
00:23:40.670 --> 00:23:42.650
I'm still a fan of thermal capsular shifts.
00:23:42.650 --> 00:23:44.329
We had excellent outcomes with that.
00:23:44.329 --> 00:23:44.509
Right.
00:23:45.349 --> 00:23:45.920
and that's been
00:23:45.994 --> 00:23:46.444
voodoo.
00:23:46.775 --> 00:23:47.464
That's voodoo.
00:23:48.289 --> 00:23:49.549
That's been, that's been banned.
00:23:49.549 --> 00:24:01.400
You are, you know, uh, you know, but if you did it right, you know, and we even published papers on this, our outcomes were great, but, um, you know, it, it's funny to see that evolution and I'm sure that's what we're about to see with FAI.
00:24:01.430 --> 00:24:01.789
Right.
00:24:01.795 --> 00:24:05.629
So, um, so, so tell us a little bit about, about the surgery then.
00:24:05.634 --> 00:24:07.039
Like what, what are the outcomes?
00:24:07.099 --> 00:24:10.549
Can, can this be something that's that's surgically addressed pretty confide.
00:24:11.603 --> 00:24:17.212
number one, I do think that peop I think there are patients that definitely need surgery.
00:24:17.363 --> 00:24:20.123
And so, you know, my.
00:24:20.752 --> 00:24:21.292
Current.
00:24:21.923 --> 00:24:25.462
Well, I think as we get older, like we get more comfortable with uncertainty.
00:24:25.522 --> 00:24:25.823
Right.
00:24:25.823 --> 00:24:31.103
And, and so like when I get a patient coming in and, and it's like, okay, is this a good surgical candidate?
00:24:31.103 --> 00:24:34.702
And like, I probably don't know right off the bat.
00:24:35.512 --> 00:24:39.383
And so like, we publish some stuff on, like, you probably need to give them three months.
00:24:39.472 --> 00:24:48.143
Um, but that said, you know, if they're, they're doing terrible four to six weeks later and you've tried everything like, Hey, you need, you need to let the pride go and probably send them anyway.
00:24:48.427 --> 00:24:48.817
right.
00:24:49.762 --> 00:24:57.982
But I think from a standpoint of, if you look at surgical outcomes is it's, uh, it probably depends on what your definition of success is.
00:24:57.982 --> 00:25:05.153
And so what we know and is that, um, that definitely some people do have success.
00:25:05.782 --> 00:25:11.782
Um, if you look at, so we published on like return to sport rates, which is another kind of pet, um, pet project of mine.
00:25:11.782 --> 00:25:17.633
And, and so what we found, so we do we found that, you know, about three outta four people go back to.
00:25:18.968 --> 00:25:21.097
And this was over, like, I think 35 studies.
00:25:21.157 --> 00:25:25.597
The problem when we did that, is there weren't very many studies that looked at well, do they go back to the same level?
00:25:25.657 --> 00:25:31.988
Like if they're a triple a baseball player, do they go back to triple a and is there, is there era is the same?
00:25:31.992 --> 00:25:33.607
Is there the same, all that type of stuff.
00:25:33.817 --> 00:25:34.298
right.
00:25:34.867 --> 00:25:42.817
So, but then since then there have been some studies published there, cohort studies, which, you know, they, uh, as, you know, have they'll those have some limitations, but.
00:25:43.357 --> 00:26:06.427
Um, the group, my PhD supervisor group did a study in Denmark and they found, okay, if you do surgery on these people and they go back to their sport, only 57% of them were going back to the same level of sport within only about 17% of them are actually performing at the same statistical level and are satisfied with their performance.
00:26:06.637 --> 00:26:07.117
Wow.
00:26:07.538 --> 00:26:09.157
And so when that came out, is everybody well.
00:26:09.563 --> 00:26:10.492
You know, it's Denmark.
00:26:11.242 --> 00:26:18.442
No, there's been some studies since then that have shown probably the highest rate as, as far as going back to same statistical level and performance.
00:26:18.952 --> 00:26:20.992
The max is probably about 30 to 40%.
00:26:21.413 --> 00:26:21.802
Yeah.
00:26:23.212 --> 00:26:23.603
Yeah.
00:26:23.603 --> 00:26:24.262
And it does.
00:26:24.262 --> 00:26:32.333
And so then, so then, then the other thing to look at is, okay, well that's athletes, maybe, you know, what about the, you know, the traditional patient and outpatient clinic.
00:26:32.333 --> 00:26:39.923
And what's interesting here is when you do, when you look at these outcome, The satisfaction rates are really high.
00:26:39.923 --> 00:26:41.542
They're like 80 to 85%.
00:26:42.173 --> 00:26:49.432
And, but if you also look at them from a patient, you know, from a, so that, you know, like patient report, outcome measures, satisfaction, they're they're high.
00:26:50.032 --> 00:26:58.222
But then if you look at them from a standpoint of objective measures, there's several studies showing that they they're not as active as they were prior surgery.
00:26:58.613 --> 00:27:03.573
You know, they essentially, they've what I think they've done is they've kind of settled and said, Hey, you know what?
00:27:04.177 --> 00:27:06.877
You know, it's like, they, they don't get back to the same activity levels.
00:27:06.877 --> 00:27:25.627
And so like, we, you know, so I have this academy through my website and, and we were talking about this patient and, um, she got back to her to, she got back and she had pain was pretty much gone, but that was because she didn't go back to the same activity level.
00:27:26.498 --> 00:27:27.728
And, but she was satisfied.
00:27:27.758 --> 00:27:29.847
So like, I'm just like, I.
00:27:30.248 --> 00:27:34.298
I don't quite get that as so, I mean, are people saying, Hey, you know what, I've done.
00:27:34.298 --> 00:27:35.198
All I can do.
00:27:35.528 --> 00:27:37.897
And it's not, you know, and they, I mean, do they settle?
00:27:37.897 --> 00:27:38.498
Are they satisfied?
00:27:38.498 --> 00:27:40.837
Like I, why are they 80% satisfaction?
00:27:40.843 --> 00:27:43.417
But they're back to sport at 30%.
00:27:43.448 --> 00:27:43.657
Like,
00:27:43.673 --> 00:27:44.633
Right, right.
00:27:44.637 --> 00:27:46.732
That, that it seems to seems to not match.
00:27:46.732 --> 00:27:47.093
Right.
00:27:47.333 --> 00:27:47.873
But, but you.
00:27:48.383 --> 00:27:54.742
You gotta wonder though, too, if there's a lot of, this is just again, the, the over the, the over focus on, on youth sports, right?
00:27:54.742 --> 00:28:06.052
And maybe these are youth athletes that they're in their twenties now and they just, they don't, they're not gonna, it's hard to play ice hockey as a 20 year old, 25 year old adult in like an, an adult league.
00:28:06.052 --> 00:28:06.232
Right.
00:28:06.238 --> 00:28:07.942
It's not as, as easy for those people.
00:28:07.962 --> 00:28:14.393
So maybe they, you know, their, their subjective scores are so high because they're out of the pain that they were in and they don't really want to get back to sport.
00:28:14.393 --> 00:28:14.813
Maybe.
00:28:14.813 --> 00:28:15.712
I don't know, maybe that's part.
00:28:17.018 --> 00:28:17.288
No.
00:28:17.288 --> 00:28:17.968
Yeah, I.
00:28:18.347 --> 00:28:18.637
That.
00:28:18.637 --> 00:28:26.137
I mean, we haven't looked at that in the hip, but I know it's been looked at in the hip, uh, in the, with ACLS and there's been a couple studies showing that.
00:28:26.228 --> 00:28:34.688
Um, and I think this is why as a clinician, like you have to, like, I always ask my patients, like, what is your definition of success and what is your goal?
00:28:34.867 --> 00:28:38.528
And I, and just kind of maybe keep, you know, keep tracking that over a period of time.
00:28:39.383 --> 00:28:46.403
Because I've seen where that, that will change and, and kind of the same thing that, you know, you were saying there, Mike is like, Hey, my hip doesn't hurt anymore.
00:28:46.492 --> 00:28:46.643
Yeah.
00:28:46.673 --> 00:28:50.801
I'm not that interested in, you know, like I try to run and it doesn't hurt anymore.
00:28:50.801 --> 00:28:54.938
So, um, but in that ACL study, you know, they showed that.
00:28:55.837 --> 00:28:58.508
Some people decided, Hey, like life moves on, right?
00:28:58.508 --> 00:29:01.448
Like I got a job, you know, they're doing other things now.
00:29:02.672 --> 00:29:06.981
and, and I think that's just the natural evolution of what we're gonna see with youth sports too.
00:29:07.071 --> 00:29:07.291
Is.
00:29:07.971 --> 00:29:13.162
You know, do these, do these surgeries, just get them back to the functional levels that they want to be at.
00:29:13.461 --> 00:29:19.551
You know, be really curious to see what happens, you know, down the road with osteoarthritis and, and how they, these things evolve.
00:29:19.551 --> 00:29:25.192
So, um, you know, you know, super interesting, uh, for me, you know, learning a little bit more about the outcomes.
00:29:25.612 --> 00:29:29.451
Um, let me ask you this for a question here, because I think.
00:29:29.701 --> 00:29:31.442
You know, I have you on this podcast.
00:29:31.442 --> 00:29:32.642
This is an amazing opportunity.
00:29:33.392 --> 00:29:36.872
Tell me what your big pearls are for the postoperative rehab.
00:29:36.872 --> 00:29:40.412
So somebody that doesn't treat a lot of these and, you know, they get one or two a year.
00:29:40.741 --> 00:29:50.731
Um, I feel like this is one of those, like surgeries, postoperative, where, you know, it's, I don't wanna say it's fairly straightforward, but you know, there's the protocol set for reason.
00:29:50.731 --> 00:29:56.612
It has nice timelines, but in your experience, what are some of the pearls to watch out for or things to focus on?
00:29:56.852 --> 00:29:58.741
Cause I feel like this is one of those procedures that.
00:29:59.307 --> 00:30:01.436
Few of those, like, Hey, don't get caught in this
00:30:04.041 --> 00:30:06.321
no, I, I, I definitely see that.
00:30:06.321 --> 00:30:07.102
And so.
00:30:08.017 --> 00:30:15.757
Like the majority of my post-ops now, just because of, you know, they come to where I am and, and they see the surgeons that, you know, so they come to our surgeons.
00:30:15.757 --> 00:30:22.836
And so then I see them is a lot of them are, you know, people that aren't doing well and, or have had a second surgery.
00:30:22.836 --> 00:30:32.706
And, and so I can only kind of, you know, guess, but typically what I see is so, uh, so like I think the key things are no number one, know what was done.
00:30:33.366 --> 00:30:35.406
And then number two, know, know your patient.
00:30:35.406 --> 00:30:39.396
So from that sample, so no, what was done like, you know, was it a labor repair?
00:30:39.396 --> 00:30:40.626
Was it resection
00:30:41.047 --> 00:30:41.436
Right.
00:30:42.366 --> 00:30:47.586
sty versus an ACE Tablo sty like an ACE Tablo sty, like you're you gotta consider the labor versus a Foor.
00:30:47.586 --> 00:30:50.196
Sty is like, like an E ostectomy.
00:30:50.201 --> 00:30:53.196
Like you can probably build a little bit faster type thing.
00:30:53.196 --> 00:30:56.406
And so, and, and I think the other thing.
00:30:57.219 --> 00:31:15.068
What I tend to, well, then also I try to look at, okay, well, what are the typical complications with somebody post-surgery and it's typically things like over or under correction, which the PT has no, uh, has no control of other than, you know, you know, looking at things like, what does the range of motion feel like?
00:31:15.068 --> 00:31:16.239
What does the in feel, feel like?
00:31:16.298 --> 00:31:18.158
You know, what does it feel like within the range of motion?
00:31:18.429 --> 00:31:22.148
Like I think basic things, you know, blocking and tackling, like Chuck Figman talks about.
00:31:23.828 --> 00:31:27.939
But I think the other thing is like, look at your patient, you know, is this somebody that's high on BA scale?
00:31:27.939 --> 00:31:30.519
Is this somebody that's generally a loose joint person?
00:31:30.908 --> 00:31:32.348
Is this somebody that's tighter?
00:31:32.739 --> 00:31:43.388
And I think the other thing is like, if the protocol says, okay, I need to be at 90 degrees and at X amount of time and they're guarding and they're spasming and they're pinching at 80 degrees.
00:31:43.689 --> 00:31:47.108
Like don't force that because there's there like the patients.
00:31:47.108 --> 00:31:51.653
I see the, when they go for the second surgery, They have this huge irritated synovitis.
00:31:52.074 --> 00:31:54.624
And like, they just, they need to get calmed down.
00:31:54.624 --> 00:31:57.594
And so like, people are like pushing them through range of motion, I suspect.
00:31:58.253 --> 00:32:09.144
And so, and, and one big thing that, uh, Phillipon talks about is, is don't push them through if their patient is pinching with their hip range of motion, especially reflection, like don't push them through that.
00:32:09.683 --> 00:32:14.963
And, you know, so like, I think it's like, I call the doctor all the time and say, Hey, you know, this person's pinching.
00:32:14.963 --> 00:32:17.844
Like, what do you think about a Medrol dose pack or something to get'em calmed down.
00:32:18.594 --> 00:32:23.124
And, you know, and also realizing that flexion is not just Stal pain motion.
00:32:23.124 --> 00:32:26.183
Like you need to go into abduction a little bit and, and externally rotate a little bit.
00:32:26.189 --> 00:32:41.304
And so it's, I mean, like you said, Mike, it's, it's not rocket science it's, but it's also like going through it and like we had this patient that, um, so one of my big thing in the clinic is like, I mentor with our, with our fellows.
00:32:41.334 --> 00:32:42.054
And so.
00:32:42.578 --> 00:32:46.118
And I go out there once a week and she had seen this patient over a couple weeks.
00:32:46.118 --> 00:32:51.669
And, and so this patient's like two and a half, three weeks out and is only like 60 degrees.
00:32:51.673 --> 00:32:57.669
And just like having a ton of pain with flexion and, and she's like trying to get her to push a little bit harder.
00:32:57.669 --> 00:33:08.304
And, and I, so I like, I feel her and she's like, And you can just tell it, I mean, it's probably like what you felt on the shoulders where it's like, oh man, this is like rising tension from the start.
00:33:08.483 --> 00:33:11.153
And you can just tell it's a really inflamed, irritated joint.
00:33:11.544 --> 00:33:12.294
And I say, you know what?
00:33:12.653 --> 00:33:13.973
Let's just back her off.
00:33:14.423 --> 00:33:17.064
And she goes, well, she's not gonna be a 90 degrees by next week.
00:33:17.064 --> 00:33:21.473
And I said, let's call the doc and let's say, Hey, this is, this is the issue.
00:33:21.473 --> 00:33:21.894
So.
00:33:22.614 --> 00:33:22.794
Yeah.
00:33:23.223 --> 00:33:29.574
I, I, I think that's that, that's an interesting way of saying, and once you get flared up, right, sometimes it's hard to, to, to get out of that.
00:33:29.574 --> 00:33:29.723
Right.
00:33:29.723 --> 00:33:36.894
We always say that as you know, you want to hit your milestones and make sure you don't flare'em up because if you get behind, you end up being behind for a while, right.
00:33:37.354 --> 00:33:39.094
Um, what, what about hip flexion?
00:33:39.094 --> 00:33:46.564
Because if there's one thing that I, I notice on the, the protocols from some of the best doctors out there is they're super, super cautious about hip flexion.
00:33:47.013 --> 00:33:47.403
Right.
00:33:47.433 --> 00:33:53.584
Um, and you know, so consequently, I've been super cautious about hip flexion, but I've never not been super cautious about it.
00:33:53.584 --> 00:33:54.814
So I don't know the negative of it.
00:33:55.023 --> 00:34:00.874
So, so what's the big deal about hip flexion and, and activity of that, that the doctors are so cautious about.
00:34:02.019 --> 00:34:07.648
I, I mean, probably have to ask each doctor cuz I mean the protocols, to be honest, Mike are like all.
00:34:07.838 --> 00:34:17.108
Ways, like, I, I know they are in the shoulder and the, in the knee, but the variability, I mean, I think a lot of it is because we haven't done a lot of basic science stuff to figure it out.
00:34:18.099 --> 00:34:35.858
But I think the big thing is, I think they're concerned about the pinching, which, you know, is that the Silvi is that actually the lab room, if it's repaired, which, you know, I mean, depends on where the labor, most labor repairs are, like on a right hip are kind of like 12 to one o'clock, which would be where that is.
00:34:36.233 --> 00:34:36.473
makes
00:34:36.788 --> 00:34:41.438
Now you're starting to see more that are at like three, o'clock almost like Tenile loading type of things.
00:34:41.438 --> 00:34:43.778
And so I, I think that's the thing.
00:34:43.868 --> 00:34:46.208
I think the other thing is there's many ways to get hip flexion.
00:34:46.628 --> 00:34:58.328
And, um, what I've found is oftentimes those really irritable patients, if you put them in quaded and have them control it themselves and, or find a different way where.
00:34:59.813 --> 00:35:10.043
as you know, with the shoulder, like if you have somebody that's has a irritated shoulder or hip and somebody else is going to take that and move that passively for them, like that's hard to relax.
00:35:10.253 --> 00:35:12.653
So that patient, you tell'em just keep, relax, relax.
00:35:12.653 --> 00:35:13.583
Well, dude, I can't relax.
00:35:13.583 --> 00:35:15.023
You've got my hip or my shoulder,
00:35:15.548 --> 00:35:15.878
Right,
00:35:16.074 --> 00:35:18.893
so, so find a way for them to do it themselves.
00:35:19.028 --> 00:35:19.449
right.
00:35:19.868 --> 00:35:29.528
And then even like, you know, like if they're supposed to be going in hip flexion and have'em do contract, relax into hip extension to try to get'em to relax and just like, see what can they get themselves?
00:35:29.528 --> 00:35:38.858
And, and cuz I think a lot of it is fear and is guardian, but I think the, the surgeons are, are probably more concerned about, are you going to be impinging?
00:35:38.918 --> 00:35:43.478
That lay room is, is my suspicion or at least that's what the dogs here are concerned about.
00:35:43.673 --> 00:35:45.833
Yeah, and I, I can see the parallel again with the shoulder.
00:35:45.833 --> 00:35:54.443
I mean, if you're, you know, active hip flex, With, let's say you're so as, for example, I mean, you have the potential for, you know, superior migration of the tomorrow head.
00:35:54.443 --> 00:35:54.773
Right.
00:35:54.773 --> 00:36:02.693
And, and, and if everything's not working together, capsular, mobility's not working together and, and you know, the forest couples of the joint aren't working together, then yeah.
00:36:02.693 --> 00:36:03.803
That could be irritable.
00:36:03.833 --> 00:36:04.343
I get that.
00:36:04.348 --> 00:36:07.553
And I, I bet you, that's why you're the Quadra position.
00:36:07.603 --> 00:36:20.713
Works even better and is comfortable for them as, you know, one, like you said, they can control it, but two is it's, it's probably getting a little bit more, um, you know, of the, of the, of the generalized movement without having to worry about just isolated.
00:36:20.713 --> 00:36:26.863
So as, uh, you lifting the hip up, so, uh, you know, super interesting, you know, thinking about the biomechanics of it.
00:36:27.863 --> 00:36:28.133
No.
00:36:28.133 --> 00:36:28.433
Yeah.
00:36:28.733 --> 00:36:34.043
I do think the, so, I mean, if you look at the studies, there are fairly consistent complications.
00:36:34.043 --> 00:36:37.523
So it's over under correction, it's scar tissue.
00:36:37.643 --> 00:36:40.673
And so, and then it's, then it's so a type of things.
00:36:40.673 --> 00:36:45.773
And, well, it depends on if the capsule was closed or not, but the, if you look at the soaz, is it.
00:36:46.598 --> 00:36:52.028
Like it tends to be like, if you have them do like trailer, like raises off the bat, it tends to flare'em up and get'em irritated.
00:36:52.568 --> 00:36:56.198
So, I mean, just simple, like heel sides versus trailer, like raises those types of things.
00:36:56.768 --> 00:37:04.088
And then the other thing is Phillipon has done this, done a couple really cool studies where he did this, like circumduction type of emotion.
00:37:04.508 --> 00:37:09.338
And he showed that it decreased the, the scar tissue rates by four, four fold.
00:37:09.338 --> 00:37:12.818
And so, you know, it's simply just, you know, putting their leg, you know, their hip in.
00:37:13.553 --> 00:37:14.393
You know, resting position.
00:37:14.398 --> 00:37:21.503
So about 30 degrees of function abduction in the ER, and just doing kind like, you know, pendulums, um, for, for the, the hip.
00:37:21.503 --> 00:37:28.223
And, and so, but then that also kind of led to doing like CPMs, which can be kind of a pain in the ass.
00:37:28.223 --> 00:37:29.753
And so, um,
00:37:29.888 --> 00:37:31.298
especially that's that's tougher.
00:37:31.298 --> 00:37:31.508
The hip
00:37:31.553 --> 00:37:32.513
uh, yeah.
00:37:32.723 --> 00:37:33.023
Yeah.
00:37:33.023 --> 00:37:35.933
It's, it's some docs use and some docs don't.
00:37:37.013 --> 00:37:43.343
I, we have had physicians send us people and said that they want us to do circum conduct for like an hour.
00:37:43.583 --> 00:37:43.823
Right.
00:37:43.823 --> 00:37:45.173
Like they want us to stand there.
00:37:45.263 --> 00:37:46.013
And I don't know.
00:37:46.013 --> 00:37:54.563
I mean, I, I think I remember, you know, the, the stats of it here, but like the weight of the leg is like a good, like 25% of your body or something like that.
00:37:54.563 --> 00:37:57.353
That's, that's, that's pretty, that's laborious for her.
00:37:57.613 --> 00:38:00.203
for a, the, to do circum for an hour.
00:38:00.203 --> 00:38:01.673
It just seemed very unrealistic.
00:38:02.633 --> 00:38:04.703
Yeah, that that's that's way too long.
00:38:04.703 --> 00:38:20.123
And typically the way I do it is like, I just, you know, I have a line supine, you know, I sit down by their hip and I put their, their tibia up over my shoulder and I just kind of gradually rotate it and, or put it on a ball and control the ball, you know, some people, so I, like, I know Philippon has done.
00:38:20.153 --> 00:38:25.583
Um, and I have not done this, but you know, those little baby suiters where you put babies in it and it kind of rocks them for that.
00:38:25.623 --> 00:38:26.583
Oh, that's a great idea.
00:38:26.588 --> 00:38:26.973
Yeah.
00:38:27.368 --> 00:38:29.678
Kind of put their foot in there and have'em hold their leg with a belt.
00:38:29.678 --> 00:38:32.018
So there's your, there's your hour
00:38:33.113 --> 00:38:40.373
I just, I mean, you just run outta Netflix shows to talk about it's just, it's just too long, but, um,
00:38:40.658 --> 00:38:42.668
you got two other patients that are doing their own program.
00:38:42.673 --> 00:38:42.938
Yeah.
00:38:44.153 --> 00:38:44.333
Yeah.
00:38:44.333 --> 00:38:45.473
Unsupervised over there.
00:38:45.478 --> 00:38:48.743
Cuz you can't even turn around because you get a 80 pound leg in your hand.
00:38:48.748 --> 00:38:49.013
Right.
00:38:49.343 --> 00:38:50.153
Uh, awesome.
00:38:50.153 --> 00:38:51.993
But um, alright, so.
00:38:52.648 --> 00:38:56.458
Let's talk non-op a little bit here because I think the majority of people are gonna see non-op.
00:38:56.818 --> 00:39:06.598
Um, I, I, I wonder sometimes if surgical outcomes are, I don't wanna say poor, but if they're not what we want, is it because it took so long to get them to surgery?
00:39:06.598 --> 00:39:07.288
Is there like.
00:39:07.393 --> 00:39:14.893
I don't wanna say a point of no return, but is there, is there, uh, is there too long in, in non-operative rehabilitation where they should get to surgery?
00:39:15.223 --> 00:39:16.753
You know, you are an expert clinician.
00:39:16.753 --> 00:39:21.433
You just told me how you like three months, but you'll pivot at the four to six week mark.
00:39:21.433 --> 00:39:23.983
Not everybody has that clinical judgment that you have Mike.
00:39:23.983 --> 00:39:24.283
Right.
00:39:24.288 --> 00:39:29.203
So, um, you know, to me is like, how do we, how do we know when.
00:39:29.733 --> 00:39:33.183
Is working and not, and, and what are some of the big things to focus on?
00:39:33.183 --> 00:39:40.713
Because I, I feel like sometimes this is a diagnosis that we see and we don't even know we're seeing at the very early stage, you know what I mean?
00:39:41.318 --> 00:39:41.678
Right.
00:39:41.768 --> 00:39:43.718
Yeah, no, it, it can be challenging.
00:39:43.718 --> 00:39:50.929
And so it can be one of those things where, you know, from, and here's where, like, I'll kind of read it again as I am not antis surgery.
00:39:51.229 --> 00:39:52.759
And so I think.
00:39:52.864 --> 00:39:59.764
I think part of this falls on nonsurgical approaches, not being providing a good alternative, to be honest.
00:39:59.764 --> 00:40:07.294
And so if you look at the literature, the literature is pretty clear that, um, number one, it's way less.
00:40:07.294 --> 00:40:11.344
I mean, there's hardly any of it compared to non, you know, compared to surgical.
00:40:11.344 --> 00:40:16.204
So there's not very much non-surgical research and, and what is out there.
00:40:16.204 --> 00:40:23.644
I mean, we have like a couple of two level two studies and in both of those studies, The satisfaction was about 70%.
00:40:23.884 --> 00:40:30.724
But even of that group of people, about 40% of them had significantly altered their activity.
00:40:30.724 --> 00:40:33.664
And, and about that same number, we're still considering surgery.
00:40:34.954 --> 00:40:38.644
So to me is, well, like it's hard for me to complain.
00:40:38.644 --> 00:40:42.334
Well, surgery may be overdone if we don't have a good alternative.
00:40:42.424 --> 00:40:42.774
Right.
00:40:42.874 --> 00:40:51.409
And so, and, and there's this really cool study that, um, Um, Lexi Wright, um, out of, well, she used to be at high point.
00:40:51.409 --> 00:40:55.849
I'm not sure where she is now, but they actually looked at all the now granted, these are studies that are published.
00:40:55.854 --> 00:41:14.039
So these are, you know, I know the clinic is different than, than research, but what we found or what they found in those studies is they, so they essentially looked ATI related exercises in different studies, which, I mean, it's a small, subset is probably a little bit biased, but regardless.
00:41:14.584 --> 00:41:19.534
What they found is like only 49% of those, those exercises were, were weight bearing.
00:41:20.134 --> 00:41:24.244
Only 5% of them were Mo involving all three planes of movement,
00:41:24.664 --> 00:41:25.204
Oh, ma
00:41:25.294 --> 00:41:26.704
like who doesn't function in all
00:41:26.764 --> 00:41:27.334
right?
00:41:27.334 --> 00:41:27.634
Yeah.
00:41:27.634 --> 00:41:28.264
That's not good.
00:41:28.834 --> 00:41:29.464
now.
00:41:29.464 --> 00:41:38.074
So, so I, I think, and even if you look at some of the postoperative, so there's been four randomized controlled trials comparing surgery versus non-surgery.
00:41:39.034 --> 00:41:43.024
And, and it, and I think so number one, surgery is not just the surgery.
00:41:43.024 --> 00:41:50.254
It's also the postoperative rehab that, that needs to be, um, reported as successful or not successful.
00:41:50.834 --> 00:42:02.776
And, and if you look at some of those postoperative protocols to me, Al like I, and we wrote this in that same paper we wrote about three months is like, I don't, I don't think, I don't think we're matching the demand that the person has to go back to.
00:42:02.776 --> 00:42:05.266
So like, are we truly loading that person enough?
00:42:05.266 --> 00:42:05.846
And so.
00:42:06.001 --> 00:42:09.661
Um, yeah, I mean, a lot of people, again are similar.
00:42:09.661 --> 00:42:12.601
They satisfied, but they, they adjust their activity.
00:42:13.306 --> 00:42:19.666
if your bony changes though, are like so large, like, you know, a huge cam, I mean, are you bound to.
00:42:21.031 --> 00:42:21.361
Yeah.
00:42:21.361 --> 00:42:22.591
So that's a good question.
00:42:22.701 --> 00:42:25.021
And, and there's a lot of really good people looking at this.
00:42:25.021 --> 00:42:30.901
So, um, a co uh, so Cola and, and a bunch of other folks are actually trying.
00:42:31.771 --> 00:42:34.561
So we, uh, like I was on a paper with him that we tried to figure.
00:42:34.561 --> 00:42:34.831
Okay.
00:42:35.161 --> 00:42:36.691
Cuz they talk about the alpha angle.
00:42:36.691 --> 00:42:38.671
Well like how big does it need to be before?
00:42:38.671 --> 00:42:39.151
It's bad.
00:42:39.331 --> 00:42:39.631
Right.
00:42:39.631 --> 00:42:47.731
And, and so, because if you look at the literature, like when S published out, he said, well, it's probably, you know, 50 to 55, it's probably the cutoffs.
00:42:48.901 --> 00:42:53.521
And then they do population studies and showed, well, you know, like Catholic population has 50 50 divide.
00:42:53.611 --> 00:42:54.091
And so, okay.
00:42:54.091 --> 00:42:55.531
Well let's, let's raise.
00:42:56.326 --> 00:43:06.646
And so in our study, we, what we, what we did is we looked across and this was, and we, we suggested 60, but that was not related to pathology or not.
00:43:06.646 --> 00:43:09.196
And so that was just like, Hey, here's a suggestion.
00:43:09.946 --> 00:43:19.246
Since then there been studies cuz to me, the big discrimination is okay, well what, cuz I mean you can have labor pathology, you can haveI.
00:43:20.116 --> 00:43:23.176
But the big thing that people don't recover very well from is condre damage.
00:43:23.881 --> 00:43:29.611
And, uh, so, so what, how bad does it need to be before it starts causing cond damage?
00:43:30.061 --> 00:43:33.661
And of course, like anything that takes longitudinal studies, right?
00:43:33.666 --> 00:43:42.121
And so there was a more recently published study that wasn't necessarily longit, it was short longitudinal and they suggested it probably needs to be like 80 degrees.
00:43:42.181 --> 00:43:49.291
And so the short answer is we don't know because 80 degrees for some people, I mean, some people at 60 degrees is gonna be bad.
00:43:49.291 --> 00:43:52.231
And so that's why, you know, I would.
00:43:53.521 --> 00:43:56.851
see research and, and hopefully I will contribute to this as far as okay.
00:43:56.851 --> 00:44:02.281
You get a patient coming in and, and what, what, you know, phenotype are they, are they, you know, are they tight joint?
00:44:02.611 --> 00:44:04.471
Are they high on base scale, low on pain scale?
00:44:04.476 --> 00:44:05.461
What is their range of motion?
00:44:05.761 --> 00:44:11.281
What's IR V versus ER, what's their genetic makeup, but we're just like, that's a long ways away, so
00:44:11.416 --> 00:44:11.806
Right.
00:44:12.016 --> 00:44:12.556
I like that.
00:44:12.666 --> 00:44:15.136
I, I, I, I think, I think that's a good way of saying it is.
00:44:15.196 --> 00:44:15.466
We don't know.
00:44:16.201 --> 00:44:17.641
But I, I think we don't know it yet.
00:44:18.061 --> 00:44:18.391
Right.
00:44:18.451 --> 00:44:26.941
And, and anytime you look at one number, right, you, you wonder if it's, it's a 3d equation that we need to be looking at, which is probably more part of it, which is why we're, we're awful of it.
00:44:26.941 --> 00:44:28.441
Like one number is never gonna be enough.
00:44:28.441 --> 00:44:31.831
It's gonna be a few different other variables that all get put together.
00:44:31.921 --> 00:44:32.711
So I.
00:44:32.906 --> 00:44:33.866
Um, awesome.
00:44:33.866 --> 00:44:34.586
So, alright.
00:44:34.616 --> 00:44:38.156
Non-op you have somebody in your hands, in your clinic right now.
00:44:38.396 --> 00:44:45.716
What are, what are some of the big things that physical therapists can focus on to maximize their outcome for a non-op FAI?
00:44:45.716 --> 00:44:47.736
What, what are some of the areas they need to focus on?
00:44:48.641 --> 00:44:48.881
Yeah.
00:44:48.881 --> 00:44:53.021
So I think it's the same thing or some of the same that I think definitely know who your patient is.
00:44:53.081 --> 00:44:58.031
And so, like, I always teach my student to think, you know, this, like I try to teach'em frameworks.
00:44:58.031 --> 00:45:01.871
And one of'em is what I call epic return E P I C return.
00:45:01.871 --> 00:45:04.781
And so with that is like, what are you educating them on?
00:45:05.021 --> 00:45:05.291
Right.
00:45:05.296 --> 00:45:15.761
So, number one, there's a lot of studies out there showing that people have cam and there's, there's a study from, uh, 2015 that showed that 60% of athletes had a label there.
00:45:16.721 --> 00:45:17.501
And, and so.
00:45:18.151 --> 00:45:24.391
You know, then it comes into, you know, so you get somebody coming in and because cuz here's the issue, Mike is these patients are frustrated.
00:45:24.451 --> 00:45:33.481
They've had the ones that I see and the ones in the studies they've had PT two or three times and they come to me and say, Mike, like I'm, I'm not even happy.
00:45:33.486 --> 00:45:33.931
I'm here.
00:45:33.936 --> 00:45:35.761
Like the doctor's making me come to see you.
00:45:36.151 --> 00:45:39.541
And so I like, I have to fail PT before I'll have surgery.
00:45:39.541 --> 00:45:43.591
And so it's like, oh my gosh, this is like patient has terrible expectations.
00:45:43.811 --> 00:45:46.411
And so, and so that makes it challenging.
00:45:46.471 --> 00:45:46.891
And.
00:45:48.301 --> 00:45:54.841
Like they've seen the radiograph, they've seen the full head or they've seen the label tear or whatever, and it's like, what is PT gonna do for
00:45:55.066 --> 00:45:55.306
Yeah, man.
00:45:55.336 --> 00:45:56.836
They just wanna get back to their lives.
00:45:56.836 --> 00:45:58.696
Like let's just get rid, get rid of this and move.
00:45:59.401 --> 00:46:06.661
And, and to be honest, like if I didn't know what I, what I know, and if I wasn't a PT, like I probably would think the similar, similar types of thoughts.
00:46:06.721 --> 00:46:07.201
right.
00:46:07.561 --> 00:46:11.671
And so I think it's, I think it's having a good open, honest conversation.
00:46:12.511 --> 00:46:17.671
And saying, Hey, so the nice thing is where I'm at is like the doc has a six to eight week waiting list.
00:46:17.671 --> 00:46:18.001
Anyway.
00:46:18.031 --> 00:46:20.251
I said, you know what, your surgery's not for eight weeks.
00:46:20.251 --> 00:46:22.051
Just, you know, gimme that amount of time.
00:46:22.051 --> 00:46:22.681
that's great.
00:46:23.041 --> 00:46:32.551
And so then, then it's like saying then over time, like, I think number one is you can't just like pelt them from the start and say, Hey, you know, all these studies show this, this and this.
00:46:32.551 --> 00:46:34.381
Like, you gotta, like, you gotta get to know your patient.
00:46:34.381 --> 00:46:35.881
You gotta get a good therapy Alliance.
00:46:36.391 --> 00:46:38.371
And so education is, is important.
00:46:38.986 --> 00:46:48.856
I think another big thing is to be honest, like I, the patients that I see and I've been guilty of this myself, is I don't think we are loading them appropriately and, and monitoring or loading.
00:46:48.856 --> 00:46:54.766
So from a standpoint of, you know, are we putting them in way bearing, are we doing transplant like the Lexi right study?
00:46:55.156 --> 00:46:58.936
And then how do we know if we're loading, you know, internal workload?
00:46:58.936 --> 00:47:05.386
Like what is there, you know, like I always tell the students is sometimes a 200 pound bench press feels like an eight RP.
00:47:05.386 --> 00:47:06.616
Sometimes it feels like a three.
00:47:07.051 --> 00:47:09.181
And then are you men, are you monitoring that?
00:47:09.991 --> 00:47:17.731
So, you know, we like in, in our, in our clinic, we have, you know, we have a zero to 10 RPE scale there, like I check their heart rate.
00:47:18.151 --> 00:47:31.291
And so then, you know, if, if they, you know, if they extrapolate to a 17 on the, you know, the six to 20 RPE scale, but their heart rate is like one 10, like what, you know, why, you know, what's going on there.
00:47:31.291 --> 00:47:33.511
And so then kind of looking at some of those types things and.
00:47:34.471 --> 00:47:39.481
And I think another thing with the individualized is every person is different.
00:47:39.541 --> 00:47:46.111
And you know, like I always show this picture to my students of these two, two students squatting, and one, one guy squats.
00:47:46.111 --> 00:47:49.651
He can squat butt to heels and the other guy can't even get to parallel.
00:47:50.521 --> 00:47:51.751
The guy don't give them the same.
00:47:51.781 --> 00:47:52.711
Like I'm gonna squat.
00:47:52.711 --> 00:47:58.891
Both those people they're gonna do both do deadlifts, but the person that can squat the parallel is probably doing deadlifts off of boxes.
00:47:59.386 --> 00:47:59.686
Yeah.
00:47:59.746 --> 00:48:01.066
They're gonna have a regression for sure.
00:48:01.651 --> 00:48:02.941
not forcing the range of motion
00:48:03.061 --> 00:48:04.141
Right, right.
00:48:04.591 --> 00:48:05.281
I, I love it.
00:48:05.281 --> 00:48:11.311
That's and, and some really good, you know, wisdom there is, you know, I, I, you know, it's the question of art and science, right?
00:48:11.311 --> 00:48:15.451
There's a lot of science behind what we do, but there's also a lot of art and clinical judgment.
00:48:15.451 --> 00:48:15.721
Right.
00:48:15.726 --> 00:48:21.871
And I know a lot of young clinicians get frustrated when they don't have that experience yet to have that clinical judgment.
00:48:22.111 --> 00:48:24.721
But that's why, you know, podcasts like this exist, right.
00:48:24.721 --> 00:48:28.291
Is, is, you know, learned from some of the things that Mike's figured out over his time.
00:48:28.651 --> 00:48:30.061
Um, you know, I think, I think.
00:48:30.391 --> 00:48:31.111
That's amazing.
00:48:31.111 --> 00:48:33.901
So, um, alright, so great talk Oni.
00:48:33.961 --> 00:48:39.061
I feel like I am waist smarter than I was an hour ago or whatever it's been, Mike, thank you for that.
00:48:39.391 --> 00:48:45.961
Um, let's hit the high five real quick five quick questions, five quick answers from you so we can learn a little bit more about you.
00:48:46.261 --> 00:48:51.871
Number one, what are you currently reading or working on or what are you doing for your own ConEd or professional development?
00:48:52.921 --> 00:48:53.161
No.
00:48:53.166 --> 00:48:53.491
Yeah.
00:48:53.491 --> 00:49:01.321
A lot, but, but in brief, it's essentially, essentially trying to, trying to look at, you know, kind of the predictive modeling type of stuff while I was talking about earlier.
00:49:01.326 --> 00:49:05.671
And then the other thing is, um, like I've always had a huge interest in shrink conditioning.
00:49:05.671 --> 00:49:10.831
So just trying to look at, you know, things like velocity based training, some of the newer things out there are the big things though.
00:49:11.566 --> 00:49:12.646
Stand current on that stuff.
00:49:12.646 --> 00:49:13.036
I like that.
00:49:13.636 --> 00:49:20.836
I feel like strength and conditioning is, uh, you know, we're getting a little bit more database now, which is really neat and it's an exciting future for it, for sure.
00:49:20.866 --> 00:49:21.316
I like that.
00:49:21.706 --> 00:49:22.486
Um, alright.
00:49:22.491 --> 00:49:27.796
What's one thing that you've recently changed your mind on or evolved your thoughts at least.
00:49:29.006 --> 00:49:34.366
So, so again, a lot of things, but probably, you know, so over my career, like I, when I first got.
00:49:35.086 --> 00:49:41.386
Like I was, you know, one of those people that like, I, like, I was an early adopter when I was in Kansas.
00:49:41.386 --> 00:49:49.546
Like I learned Asim and then, then I got into academia and I became this evidence based where like, you know, all these things that are awesome modalities.
00:49:50.236 --> 00:49:57.166
And then, you know, like I started having some family members have issues and I had like this, uh, big, uh, low back pain blowout.
00:49:57.166 --> 00:50:02.056
And, um, like I would've, if you could've put tape on me and I would've felt better, I would've done
00:50:02.446 --> 00:50:03.106
Of course.
00:50:03.991 --> 00:50:15.871
So I think the big thing is just like, not poo-pooing things that, you know, patient thinks is important, but also, like I always give this talk to my, my students about.
00:50:16.936 --> 00:50:20.926
Um, you know, like apple pie versus a main course.
00:50:20.926 --> 00:50:30.856
So like, if, if you, like, as long as my athletes and patients are doing the meat potatoes of what I want them to do, if they wanna put tape on themselves and, and do it themselves, like, I'm, I'm fine with that.
00:50:30.916 --> 00:50:40.936
And so just kind of being a little bit more open to like patient centered approach and not, you know, you know, ragging on them at, you know, that there's no evidence for that type of stuff.
00:50:41.281 --> 00:50:44.191
Especially if you're getting your goals accomplished too.
00:50:44.251 --> 00:50:44.641
Right.
00:50:44.641 --> 00:50:46.081
You know, if it's part of that, that program.
00:50:46.081 --> 00:50:46.321
Yeah.
00:50:46.381 --> 00:50:54.841
And I've definitely seen people do that, that, that, you know, I, I don't know what it is about it, but you, you never wanna make the patient feel stupid or bad about themselves.
00:50:54.901 --> 00:50:55.261
Right.
00:50:55.266 --> 00:51:06.181
And you, by, by poo poo in their ideas, sometimes that happens now, you know, every now and then you have somebody doing something that you think may be negative, but but most of the time, that's not the case.
00:51:06.526 --> 00:51:06.916
No.
00:51:07.006 --> 00:51:12.916
Yeah, I was, I was in the athletic tra so last year I had spent a year in ath in the football athletic training room and yeah.
00:51:13.816 --> 00:51:15.226
You had to draw the line sometimes.
00:51:15.226 --> 00:51:15.556
So
00:51:15.856 --> 00:51:16.486
Exactly.
00:51:16.996 --> 00:51:18.286
Well, well said, I like that.
00:51:19.096 --> 00:51:20.026
Um, alright.
00:51:20.026 --> 00:51:26.476
What, what is you probably, I mean, you deal with this every day, so this is gonna be a good one, but what's your best piece of advice that you give your students?
00:51:27.376 --> 00:51:42.496
Yeah, so I like, I do a lot of what I call dad talks, but probably the big one that I'm on right now is, um, uh, what, uh, what, uh, Jane or, um, Dunning from the Dunning crew, uh, what he calls desirable difficulties and essentially.
00:51:42.976 --> 00:51:47.296
Is trying to enjoy the process versus the outcomes.
00:51:47.296 --> 00:51:55.186
And so, like, I think maybe it kind of gets back to what you were saying either earlier is like young clinicians get frustrated with not seeing outcomes or understanding it.
00:51:55.186 --> 00:52:02.615
But it's like, if, if you look at the literature on this is, and this is what I try to have students do is like make their own cases, you know?
00:52:02.615 --> 00:52:06.425
Cuz like I said, what if this patient was impingement, this is how they look, but okay.
00:52:06.425 --> 00:52:07.235
Write it up your stuff.
00:52:07.235 --> 00:52:07.385
So.
00:52:08.255 --> 00:52:24.575
Like going, you know, trying to struggle with the process and trying to struggle with learning, you know, communication and that type of stuff, because the studies show that if you struggle with that and you reflect on, on your performance and you adjust what you're doing like that, they, you learn it better.
00:52:24.575 --> 00:52:26.525
And then also it resonates better with you.
00:52:26.525 --> 00:52:26.915
So.
00:52:27.410 --> 00:52:27.800
killer.
00:52:27.830 --> 00:52:28.550
I love that one.
00:52:28.580 --> 00:52:29.120
Awesome.
00:52:29.480 --> 00:52:31.060
Uh, what's coming up next for you, Mike.
00:52:32.360 --> 00:52:35.900
So, you know, we, we ha uh, we have our own continuing education company.
00:52:35.900 --> 00:52:54.410
We do some online type of stuff, but, you know, so what's not really cool is, um, going to the, uh, lower Chey summit in Paris, uh, in October and, um, talking about some hip stuff and then, um, just doing, uh, so from a research standpoint, we're doing return to sport testing and trying to look at, you know, prognostic types things.
00:52:54.740 --> 00:52:59.000
If you know, somebody squats this much, like, you know, what is their, what is their prognosis?
00:52:59.000 --> 00:52:59.720
So a lot of cool.
00:53:00.260 --> 00:53:00.800
That's great.
00:53:00.800 --> 00:53:02.180
And, and what's your website again?
00:53:02.180 --> 00:53:04.580
Just so the listeners can hear, I'm gonna put in the show notes, but
00:53:04.715 --> 00:53:05.045
Right.
00:53:05.225 --> 00:53:08.435
Uh, rehab learning center.com all, all one word.
00:53:08.810 --> 00:53:09.650
that's, that's easy.
00:53:09.650 --> 00:53:10.430
That's a good domain.
00:53:10.435 --> 00:53:11.270
You got, that was pretty
00:53:11.375 --> 00:53:11.645
Yeah.
00:53:11.645 --> 00:53:13.955
It took a, took a long time to figure out what we were gonna do with
00:53:14.120 --> 00:53:14.630
I like that.
00:53:14.630 --> 00:53:20.990
I, I own like 10 different domains, like similar to that, just for, for the last 15 years.
00:53:20.990 --> 00:53:23.030
Like And so if you were
00:53:23.225 --> 00:53:23.675
probably the one.
00:53:23.675 --> 00:53:25.495
I probably wanted something you had and
00:53:26.690 --> 00:53:28.280
I was like, I'm just gonna buy'em all they're 10
00:53:28.505 --> 00:53:30.995
You were, you were like gonna charge me a thousand dollars.
00:53:30.995 --> 00:53:32.045
I'm not doing that.
00:53:32.065 --> 00:53:32.845
Hey, that's not me.
00:53:32.845 --> 00:53:33.505
That's GoDaddy.
00:53:33.505 --> 00:53:34.315
They're the middle man.
00:53:34.315 --> 00:53:34.555
Right?
00:53:36.145 --> 00:53:36.775
that's awesome.
00:53:36.805 --> 00:53:37.105
All right.
00:53:37.105 --> 00:53:40.435
So in other than rehab learning center.com, how do we learn more about you, Mike?
00:53:40.435 --> 00:53:43.825
I know, I know you're in a few different places, but where's the best place to find you.
00:53:44.435 --> 00:53:44.735
yeah.
00:53:44.740 --> 00:53:52.745
So that's probably a good way to directly contact me and or Twitter at Mike Raymond, and then, uh, Instagram at, at Michael Raymond, probably the best ways.
00:53:52.895 --> 00:53:52.955
Yeah,
00:53:53.165 --> 00:53:53.555
Awesome.
00:53:53.555 --> 00:54:04.325
And please take advantage of that because Mike is super open on Instagram, especially that's where I think I see you interacting the most, but, um, you know, super open and, and there for you, if you have questions or anything.
00:54:04.330 --> 00:54:11.705
So, um, you know, thanks so much for this episode, Mike, and for all the new things that you've, you've been up to, it's been super helpful for me, I'm sure for my listeners as well.
00:54:11.705 --> 00:54:13.505
So thanks for, for coming on the podcast today.
00:54:14.315 --> 00:54:14.855
no problem.
00:54:14.855 --> 00:54:16.115
I really appreciate being asked.