Catherine Dale - Raising awareness of Hip FAI Syndrome

As a now ‘ex’ member of PFRAC I wanted to share my story about my love for running, injury (hip FAI syndrome), surgery, osteoarthritis and the realisation that at 33 years old I am now a ‘retired’ runner, who will at some point in the near future need a bilateral hip replacement. By doing this, I hope I can raise awareness about Hip FAI syndrome, a condition which affects competitive runners and young active adults and which can lead to the early onset of osteoarthritis…..

Where it all began……

I love running, although my love for running didn’t become a passion until I was in my late 20s. As a child, I grew up in Hull in a ‘running family’. My dad ran for City of Hull AC and my mum for Springhead Harriers and both competed in middle/long distance and cross country races. I remember my dad running the London Marathon in the 1980’s and coming home with his Mars foil cape – I thought he was a super hero!!  As soon as we were old enough, my sisters and I also joined Springhead Harriers and competed in races. We regularly spent our weekends spectating and supporting at cross country & track races eating cheese sandwiches out of an ice-cream container!

Out of the 3, I was always the average one and running was never ‘my thing’. As I got older, I had more of a preference for field events (high jump, shot put, long jump). By the time I got into my late 20’s, juggling working full-time and being a mum, I needed something that was just for me and that would help me improve my overall fitness; running was the first sport that came to mind so I bought myself a pair of trainers and some kit and that’s what I did – I ran.

In the beginning, it was more of a solitary hobby, just me, my iPod and my thoughts. After a few months, I entered  and ran a local 10K race. I entered a few more races and pushed myself further and then decided it was about time I joined a club. So, after a bit of research, I joined Penistone Footpath Running Club (PFRAC). The adults and juniors trained at the same time so it was a perfect fit for me to go with my daughter and introduce her to running too. From Day one, I felt welcomed and as though this was a club where I was supposed to be. The club taught me a whole new world about running – speed sessions, hill sessions, long runs, short runs, fell runs, trail runs – you name it I tried it. The club also introduced me to new people and I soon made some very good friends.  I was soon entering half marathons, trail runs in the Lake District, fell races, charity races. Running became a passion; a daily necessity; part of who I am and I enjoyed feeling part of the ‘club’ and the constant challenges I could set myself.

My injury started in 2011, I was running the Sheffield Half Marathon at the time and by 10 miles I had pain in my right thigh. I ran through it and crossed the finish line limping. I went to see a physio who thought I had an unstable pelvis and ITB syndrome. He advised rest and some exercises. However, I was due to be running the Liverpool Marathon that September so continued to train and didn’t rest, opting instead for regular sports massage. The pain persisted and I found that my hip would be very stiff for days after my long runs. All of a sudden, I had problems getting in and out of my car, walking up stairs, pain at night and restricted ROM (Range of Movement). It felt like something was stopping my hip from extending.

By July 2011 I was running about 35 miles per week and after one long Sunday run the pain in my hip stopped me in my tracks. So, I went to see my GP who thought I had hip Bursitis and referred me for more physio. By this time, August 2011 I’d stopped running completely. After just 2 physio sessions I asked my GP to refer me onto a specialist as the pain was just not subsiding. By October 2011, my appointment came through to see a specialist at my local Hospital. Luck was on my side that day because the man I saw knew quite a bit about hips. A runner himself and sufferer of hip problems he recognised the symptoms I was experiencing immediately. He did some physical tests and said he was 99.9% sure I had a labral tear in my right hip.

 I was sent for diagnostic tests in December 2011 – the first being an MRI arthrogram (they inject contrast dye into your hip joint guided by an x-ray and then you have an MRI – not a very nice experience). The results from this confirmed I had a labral tear in my hip joint & I was advised I’d need a hip arthroscopy to repair it. At this stage, they could not see any abnormality which could have caused the tear and advised I’d be ok continuing to run (short and flat) until my surgery and there was no reason why I couldn’t make a return to running post op.

Unfortunately, my local PCT (Wakefield Primary Care Trust) did not commission or fund hip arthroscopies (it’s a relatively new procedure) so my referral was declined. My case went to a special case panel at my local PCT and they refused to fund my surgery on the basis that there was a lack of reliable evidence that hip arthroscopy works and is cost effective. By this time, it was early 2012 and I would not accept that I could not get the surgery I needed on the NHS. I did lots of research and found stories on forums like Runners World of patients who had had this surgery funded by the NHS, many who lived in neighbouring health trusts.

So, I put my case together and got my local MP involved and challenged my local PCT. By April 2012, they wrote to me advising they had now changed their commissioning policy and they would now fund my surgery. I was referred to Mr Jon Conroy, a hip specialist at Harrogate Hospital and had my first appointment in June 2012. He did a simple x-ray of my hip which showed not only did I have a labral tear but I also had FAI syndrome in my right hip and this was the abnormality which had caused the tear.

FAI is a condition of too much friction in the hip joint.  Basically, the ball (femoral head) and socket (acetabulum) rub abnormally creating damage to the hip joint.  The damage can occur to the articular cartilage (smooth white surface of the ball or socket) or the labral cartilage (soft tissue bumper of the socket). FAI generally occurs as two forms: Cam and Pincer.  The Cam form describes the femoral head and neck relationship as aspherical or not perfectly round.  The Pincer form describes the situation where the socket or acetabulum has too much coverage of the ball or femoral head.  FAI is associated with cartilage damage, labral tears, early hip arthritis, hyperlaxity, sports hernias, and low back pain and is common in high level athletes, but also occurs in active individuals.

I was diagnosed with both CAM and PINCER impingement in the ball and socket of my hip joint. This impingement had caused the labral tear and was probably a congenital condition. He booked me in for a hip arthroscopy in August 2012 and told me to stop running completely.  During the surgery, your leg is put in traction and the ball and socket dislocated – not very pleasant! The morning after the surgery, Mr Conroy came to see me and told me he had debrided the impingement on my ball and socket, and anchored my labrum back together. The bad news was that I had a whole part of my joint that had degenerated (worn away), resulting in stage 3 arthritis (stages are 1-4 with 4 being the worst. By stage 4, total hip replacement is inevitable). Imagine my hip as a wedding cake, well a big part of my hip joint has no icing, or marzipan and is down to just the fruit cake, meaning that in parts, my hip joint is just bone on bone – there is nothing there to protect it. He told me there and then in my hospital bed, at 32 years old that I would need a THR (total hip replacement) in the near future and that I wouldn’t be making a return to any high impact sport i.e running. My focus now had to be on preserving my joint for as long as possible.

I really didn’t expect this news, I thought that the surgery would cure my injury and allow me to run again. It took me some time to get my head around this and I found focusing my energy on rehab really helped. I was on crutches for the first 4 weeks, off work for 6 weeks and during this time I began swimming; a sport I’m naturally good at and enjoy.  However, just a few weeks into my recovery, my left hip became symptomatic and at my 6 week follow up in October 2012 I was diagnosed with exactly the same condition in my left hip which was an even bigger blow and I was booked in for surgery for February 2013.

I was still walking with a walking stick up until about December 2012 and having to take tramadol just to sleep pain free.  I had to accept that I could not be this active person I once was. I still have hip stiffness, find it painful to walk long distances, to get in and out of my car and up the stairs.

I’ve now had my left hip arthroscopy and thankfully the degenerative damage in my left hip is only stage 1 arthritis; probably because it was operated on sooner from the symptoms first appearing. I know I’m going to need a bilateral hip replacement in the near future, but at 33, I want to put this off for as long as possible because the lifespan of a replacement hip joint is much shorter in younger patients.  This time I will approach my rehab differently and patience will be my best friend because I want my rehab to be successful and I accept now there is no short term fix. I will be back in the gym in the next few weeks and will focus on a combination of strength and cardio (from swimming, walking and cycling).

If I’m honest with myself, being told I can no longer do something that I love has been really, really hard (emotionally and physically) and probably one of the hardest things I’ve had to come to terms with; tell this to a non-runner and they just don’t get it. I miss the feeling I used to get from running; the challenge and being part of PFRAC.

I’m glad I had the opportunity to experience running and I have memories, medals, photos and t-shirts and a PFRAC vest that I will treasure forever. It’s now part of my past and I have to focus on my future. I’m an ‘ex runner’ and I just have to accept that. In the bigger picture, there are a lot of worse things that could’ve happened to me.

To keep me focused during my recovery I’ve signed up to do an open water swim course in the Lake District in the summer with the aim of joining Wakefield triathlon club and doing my first relay triathlon in 2014 (just without the running bit) and some open water swims. I’ve also started drawing, something I’m good at and enjoy but never had the time to indulge in. I still have all that energy and motivation for running and I’d like to channel this into others so junior coaching maybe an option for the future.

If I could change any part of this journey, I just wish I had stopped running as soon as the pain began, maybe that way I wouldn’t have done so much damage to my joints. There are FAI success stories out there, lots of them, and some high profile ones, where people have returned to running but it tends to be reserved to those people who haven’t developed arthritis. If something hurts, STOP RUNNING and don’t give up finding the reason for the pain and some treatment.

On the plus side of this, I’ve done so much research on running and FAI that there is nothing I don’t know about the condition; I’ve challenged my PCT and they have changed their commissioning policy and now fund hip arthroscopy but If I could take anything from this, I would like to raise awareness of this condition and warn other runners about the dangers of FAI and the early onset of hip arthritis and to recognise the symptoms. I’m not sure the condition is even understood by GPs never mind the general running public!

So What does FAI of the hip feel like?

Symptoms of hip impingement most commonly include groin pain, but frequently can occur in the thigh, buttock, or lower back. The pain is often intensified by prolonged sitting, standing and walking. walking. Many athletes often describe pain in the groin with deep flexion or rotation of the hip during activity. The pain can be described as a dull ache or a sharp sensation. Occasionally, a popping or clicking in the front of the hip is described. Daily activities such as getting in and out of a car, putting on your socks and shoes, and climbing up stairs can be painful. The onset of symptoms is usually gradual. Hips may also be stiff, buckle and a sharp, locking hip pain may occur.  If you experience any of these symptoms over a period of time you should rest and go and see your GP.

Why does it occur?

No one knows if FAI is a condition that begins at birth (congenital and genetic association) or develops during periods of growth (acquired).  It is likely a combination of one’s genetics and environment.

How do you get FAI?

Some experts believe that significant athletic activity before skeletal maturity increases the risk of FAI, but no one truly knows.  Significant contact sports (i.e., football) and male gender are associated with Cam impingement. Pincer type impingement may be more common in women.