Painful Exercise In Rehab – Yes, No, Or A Lot To Think About

Whether rehab exercises should be painful or not has become a recent topic of much discussion. As we have started to value the role of (optimal) loading in rehab, and that we can get patients back to moving and loading pretty early in the rehab process, we have also got to appreciate that this is unlikely to happen without experiencing any pain.

If you have any type of understanding about pain then the simple question of “should we use painful exercise?” suddenly might not look so simple!

Rather than a simple yes or no, there are a bunch of questions to be answered, such as how much pain is OK? Who may or may not benefit? And what is the best way to manage the process? Especially if all does not go to plan!


From a data standpoint it would be great if we had have something that we can use to guide us here. Low and behold we do, and its open access.

Smith et al looked at this question in 2017.

Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis

This systematic review and meta analysis looked at 9 trials in which varying degrees of painful exercise were used. They found that painful exercise did NOT result in statistically worse outcomes across a short, medium or long term follow up. There was a small statistical benefit in the short-term for painful exercises as highlighted by the standardised mean difference of around 0.2 (SMD = effect size for a meta analysis). So from a research standpoint this is positive news.

One thing to note here from a clinical standpoint is, that using painful exercise is no GUARANTEE that it will have a positive effect for your patient. All statistical tests only give us the PROBABILITY of an effect, so the likelihood is that it will, but when we look at the confidence intervals (measure of variability) for the mean SMD for painful exercise, for the majority of the studies we can also see that they cross into a negative effect and in some of the studies quite substantially.

The variable effect of exercise on pain (although over a shorter time frame) was also shown by O Neill et al’s recent look at the acute effects of isometrics *Here*. Although, of course, isometric exercise and painful exercise is not the same thing, the point here is the highlighting of the variable effects from exercise. For patients with higher baseline pain isometrics actually increased their pain post exercise and this is the benefit of looking at individual responders within a study not just the group average. Those with lower pain at baseline seemed to receive more analgesia from isometric exercise.

BUT at the very least I think we can say that the likelihood is that it will not have detrimental effect. So as rehab can often be painful we can be reasonably confident but without seeing painful exercise as some sort of fire and forget panacea and also appreciate the individual nature of pain.

We could debate the mechanisms of HOW painful exercise might work from pain habituation to conditioned pain modulation and perceptual mechanisms but in essence we don’t really know at this point in time and this might be different or in different combinations for different people.


The benefits can be both physical AND psychological.

Firstly, it allows patients to get in MORE exercise. If they are not being limited by pain (or pain contingent if we are being fancy :) then they can get a greater dosing than if they stopped due to it being painful. It is important to add though that we currently don’t know what optimal dosing is for exercise having an effect on pain!

Secondly, it sends the message that hurt does not equal harm. The problem can be painful and still settle down if managed in the right way. This may give people a new insight into their pain and how they can manage it.

Pain self-efficacy may also be built experientially, so using painful exercise as a tool might be an option to help do this.

Clinical Application

So it’s great to have some objective data on this subject, but as we know getting that into clinical application is not always straightforward.

Firstly don’t be afraid of some pain! The likelihood is that it won’t cause a worse outcome. But as we are dealing with thinking, feeling HUMANS, it is OF COURSE not as simple as this, but more on that later.

One of the issues with always looking to be pain free with exercise or continually treating pain, is what does that say ABOUT pain? On one hand we are telling people hurt does not mean harm but our actions might not be saying the same thing. If pain is OK, if it is normal then in the process of getting it better we might have to endure a little bit of it.

But how much is OK is a key question? Studies that have allowed painful exercise have ranged from not increasing baseline symptoms during or post exercise up to 5/10 on the VAS.

We know the limitations of the VAS as a REALLY subjective scale so perhaps we could introduce the idea of pain being tolerable or intolerable rather than a numerical score.

Screen Shot 2019 01 21 At 13.16.00


Now tolerable might be a bit sore but it does not really get in the way. Intolerable might be thought of as getting in the way of our daily activates, maybe having an effect on our sleep and generally making life a bit miserable. This is going to be different for different folk so hence why the concept of tolerable becomes important.

We would also like to know how the pain is settling down. So pain that is not really calming down after the exercise stimulus or keeps on getting progressively worse over a number of days as the exercises are performed is probably not a great idea. We would like to see a nice stimulus response with only slight increases above baseline (tolerable remember : ) that calms down gradually over 24-36 hours, quite similar to delayed onset muscle soreness (DOMS)

So on the issue of DOMS, it is important to identify if the increase in pain is actually the same as the original symptom. Post exercise soreness is quite normal but for those that are unaccustomed to exercise this might not be recognisable especially for a currently painful area. Defining what is pain and what is soreness might be a good sense making exercise for some patients. Although we don’t know that progressive overload is required with exercise in rehab, it probably ia a good idea, so having some sort of tolerable baseline for patients to progress or regress from is a great idea too. This is also might have an effect their self efficacy using exercise too which, of course, is a bonus.

Pain Is Not The Only Issue

Potentially the most problematic area with painful exercise, and one that is really under discussed, may be more about the psychological aspects that are associated with the pain and how they can affect the person. One of the best prognostic factors for recovery in a number of body areas appears to be pain self efficacy, *here* is a recent paper from Chester et al and also from Foster et al *here*  Pain self efficacy, something I have written about before also *here*, is the ability to carry on normal functioning despite of pain. It is important to note that those with higher pain self efficacy also tend to adhere to exercise better.

So someone’s pain self efficacy is going to be a KEY factor in whether they are able to tolerate having pain and being able to carry on functioning which maybe a fundamental skill at the heart of painful exercise especially if it can take 24-36 hrs to settle.

Predicted outcome is another key prognostic factor and if someone believes that increased pain will result in a negative outcome then this could have a negative effect on the actual outcome.

Jack et al *here* found that the number one reason for poor adherence to exercise programs was that people did not want to make the problem worse. So painful exercise coupled with negative beliefs about pain, low pain self efficacy and a poor predicted outcome may not sit well together.

A qualitative piece “Exploring experiences, barriers, and enablers to home- and class-based exercise in rotator cuff tendinopathy” from Sandford et al also found that a fear of making the issue worse was a key factor in reduced adherence to exercise.

What Can We Do?

Firstly you could screen people for these factors if you feel they are required. We have tools such the Pain Self Efficacy Questionnaire  (PSEQ) and the shorter version the PSEQ-2.

One caveat with using questionnaires, in my opinion : ), is it does allow us to get a score to assess confidence and resilience in managing pain but it perhaps does not tell us about things that are specific to our patients. So being able to weave this into a good subjective that teases these more personal parts of the narrative out is a must.

Also ASK about their expected outcome from the treatment and what would it mean to you if it was painful.

“Do you feel like this exercise will work for you?”

“Do you have any concerns about doing this exercise?”

It might be that someone tells you that they have tried exercises before and they did not work or that they feel it might make the issue worse, especially if it hurts.

It might also be important to discuss with ALL patients what their beliefs are around pain. These might be that pain indicates they are doing more damage to their bodies or they will not be able to work because they have pain or implications for future functioning. It can often be what the pain MEANS to the patient that is the real issue rather than just the sensation of the pain itself.

A key factor to remember is regardless of whether painful exercise is positive or no worse than non painful exercise, a negative belief may stop your patient from exercising


One of the most powerful tools we have at our disposal is EDUCATION, I am not always a huge fan of this term as it can imply a teacher pupil relationship. But in order to provide effective education to people we first have to build rapport and then understand what they may need to know more about.

We can educate on a range of things from the effectiveness of exercise for many issues, that painful exercise is often not detrimental, that pain self efficacy is an important prognostic factor and what pain may actually mean and its relationship with physical damage. It may also be worth talking about the process and what to expect, and often that it is a process of trial and error to get the right level and desired response.

This has to start with understanding the patient, their history and belief structure.

Where You Start Is Not Where You Have To Finish

Do we have to jump straight into painful exercise? I don’t think so. It is not REQUIRED but it is also not harmful.

An important point to make is that for someone with very negative beliefs about pain, reduced pain self efficacy and poor beliefs about the outcome, challenging them right off the bat with painful exercise might not always be the best thing to do. As they build trust in you and confidence in their bodies then pushing into pain progressively might sometimes be a better route.

We know that giving people the option to avoid pain can actually maintain pain avoidance, so whilst not advocating avoidance behaviour confronting these things may take a little time, confidence and education, especially if the person has a lot of negative pain and avoidance based beliefs.

Those that persist in doing painful things that have NOT provide a therapeutic effect may benefit from non painful exercise for a while too. If you feel that pushing into pain has not given the desired response when looking at their history then a break or change in dosage could be just the ticket.

Those with higher levels of pain at baseline on average seem to have worse clinical outcomes so this might also lead me to reason that maintaining this level of pain through exercise might not always be a good idea.

There are no real hard and fast rules here only individuals and individual considerations.

What If It All Goes Wrong???

This is where self efficacy may come into its own. Empowering your patients to self manage maybe valuable in the exercise process.

As we hopefully have told the patient BEFORE they embark on an exercise program I can often be trial and error. Have we enabled our patients to adapt their exercise dosage if it goes a bit wrong? *Here* is a short piece on dosage in rehab

So do your patients know what to look out for in terms of symptoms?

Do they know how to adjust the dosage? This could be in exercise frequency, intensity and time, sets and reps (volume).

Are they able to contact you to ask questions? Do they know this?

I think these are all required aspects of pushing into pain.

A patient I saw last week had religiously persisted at pushing into his painful rehab exercises every 48hrs. He believed if he did what he was told he would get better (the trust!). But after 3 months there was not the desired outcome. In this case he was given no indication what to do if this happened, just blind faith on all sides that he would get better.

Key Points

  • Painful exercise DOES NOT produce worse outcomes from the research we have
  • Research does not guarantee your patients response to painful exercise
  • It is not just about the PAIN sensation! What does the pain mean and how does it affect behaviour such as exercise adherence?
  • Pain self efficacy and predicted outcome are important psychological measures and can be discussed and measured
  • Think about education around the exercise and the pain response
  • It does not need to start with painful exercise!
  • Empower your patients to self manage


Why Weak Glutes Aren’t A Reliable Predictor Of Low Back Pain

It seems we are constantly trying to find causes for low back pain with our patients.

Quite often we are caught up looking for biomechanical issues (which there often are) and avoiding other things that could influence a person’s pain.

One such instance is the possibility that weak glutes are a contributing factor.

I recall seeing one of my instructors demonstrate this (what I perceived to be) complicated movement test where my patient was lying prone and having them extend their leg. There was a specific pattern where the muscles in the low back down through the glutes and hamstrings were supposed to move.

This would be followed up with the comment: “your glutes aren’t firing”!

While I watched this all I could think was…”there’s no way I’m going to remember what order all of this goes in”!

But, when done with confidence and a really good explanation, it seemed to make sense to me, and the patient.

So, I worked through the low back, glutes, and hamstrings, and the patient felt better after the treatment.

I proceeded to pat myself on the back for a job well done!

However, the next time a patient came in for what I thought was the same issue, I couldn’t remember this specific pattern of movement and what it was supposed to tell me! Why couldn’t I get this!?

Well, in reality, I really didn’t have to and here’s why.

Limitations With Testing

There are a couple of tests used to see if the glutes are a contributing factor to low back pain, so let’s look at both of them.

The prone leg extension test1 is pretty commonly used to test for low back pain and lumbopelvic function (this is the one my instructor was demonstrating to me).

The pattern of movement you’re supposed to see is (if you were testing the right side) right glute max, right hamstring, left lumbar erector spinae, right lumbar erector spinae, left thoracolumbar erector spinae, then the right thoracolumbar erector spinae. A delay in glute max recruitment is supposed to show a dysfunctional pattern of movement.

There is a whole list of other patterns that are supposed to mean other things, but it’s a long list and more than I want to get into for the purposes of this post.

A studyshowed there was no consistent order of activation during the test and glute max was the last muscle to become activate with time ranging from 0.07 to 0.676 seconds in delay.

Now, these tests were done with proper EMG testing, so I have to wonder…how would we ever be able to properly assess this just using touch and vision!?

Another test we were taught was “Trendelenburg”, or “SLS” to assess for glute weakness possibly contributing to back pain. 

With this test, a practitioner stands behind the patient and has them raise one leg so the hip is between 60°-90° of flexion. A positive test shows lateral pelvic tilt on the stance leg, which is supposed to represent glute weakness on that side.

One study 2 compared the differences between those with chronic low back pain vs. a control group using Trendelenberg. It actually showed the number of positive tests was no different between the groups. There was also no difference in glute med strength between those who scored a positive and negative test.

Since there was an equal number of positive and negative tests between both groups it showed this test is unreliable to differentiate between those with chronic low back pain and those without, nor was it reliable for demonstrating a difference in glute med strength.

Another study 3 actually injected a superior gluteal nerve block to see if there were any alterations in different movement variables. They found after the injection there was no difference in contralateral pelvic drop, hip adduction, or hip abduction due to reduced strength of the glutes post-injection.

The researchers found this surprising as an impaired gluteal nerve has always been associated with the SLS test.

So, in other words, lateral pelvic drop is not associated with weak glute med muscles in our patients who are dealing with chronic low back pain. It was even suggested that glute med strength of less than 10% of body weight is required to actually get a positive SLS.

The suggestion was also made that in order to maintain your stance during this test it is because of all muscles attaching to the greater trochanter working together combined with the mechanical force of the iliotibial band. This shows a positive SLS is more likely a global issue rather than a specific spine and pelvis issue.

In light of their findings they showed how this test could not distinguish between who was experiencing low back pain and who wasn’t, nor could it identify those who had weak glutes, and in fact demonstrated the test was probably due to some other issue altogether.

Another study 4 showed the presence of low back pain was a combination of higher BMI, signs of hip abductor problems, significant glute med weakness, gluteal tenderness, and a positive SLS (but the strength testing was admittedly not reliable in the study). However, this study showed something else that is probably far more significant which we will look into next.

It was unclear if glute med muscle weakness was the cause of the low back pain…or just a consequence of it.

Muscle Activation, Weakness, Or Protection?

Quite often when discussing this kind of thing and it’s relation to low back pain, the discussion can revolve around not only issues with the glutes, but also hamstring length and activation patterns between the two.

Inevitably when discussing “weak glutes” it’s due to an S.I. joint “dysfunction”, or this dysfunction is causing the weak glutes. But really, what is dysfunctional with the S.I. joint in this case?

They 5 described S.I joint dysfunction as; low back pain below L5, pain over the posterior aspect of SI joint around PSIS and buttock with or without above the knee leg pain. They used a combination of three SI joint provocation tests (posterior shear, compression, distraction, and sacral thrust) that showed good sensitivity and specificity (although the sensitivity rating was much higher).

When we look at the discussion around which muscles are “activating” with certain movements it is usually centered around the context of the pain-spasm-pain model which suggests pain results in increased muscle activity, in turn creating more pain.4

Or, the pain adaptation model which suggests pain reduces activation of muscles when active as agonists and increases activation of muscles when active as antagonists.They say this will reduce movement and ROM which would, in turn, prevent mechanical pain and further damage to the tissues.

The funny thing is that while both of these models are trying to prove the same thing, they end up contradicting each other quite a bit and neither of these ideas can predict how back pain will affect muscle activation.

There is lots of discussion around both increased and decreased muscle activation due to pain which results in disrupting motor control. However, this systematic review 6 argues that increases in muscle activation is an adaptation that occurs for various reasons, and those changes are mainly to avoid harmful stress placed on already injured structures, and to increase stability around the spine.

In each case, they looked at any changes that were task-dependent, related to an individual problem, and highly variable between each patient. This also shows those changes are functional since they are trying to reduce unpleasant stress and provide stabilization to the spine.

One common thread through most of the research cited is glute weakness in relation to back pain. However, it’s a bit of a chicken or the egg, is the weakness a result of reduced use because of pain, or did the weakness cause the pain? I’d venture to say it’s due to the reduced use.

While this can all sound maybe a little complicated and like word salad, when we look at everything we know about pain, what is this actually telling us?

One thing we know for sure that pain is ALWAYS a protection mechanism. So, if something in our body has a decreased ROM for a period of time in order to prevent stress in a sensitive area, this is just simply a way to protect that area. If those altered movements are also providing extra support to stabilize something, it’s actually doing this to protect the area! With this understanding we have to ask, does it really matter what order a muscle fires in (especially because we’d never be able to accurately assess this with just the human eye)? What we should be concerned with is calming those sensitized areas down, reassuring the patient they aren’t broken, and educating them as to why they’ll be okay. Then get them moving in pain-free full ranges again and help strengthen the area, build up that resilience!



  1. Lehman GJ, Lennon D, Tresidder B, Rayfield B, Poschar M. Muscle recruitment patterns during the prone leg extension. BMC Musculoskeletal Disorders. 2004 Dec 1;5(1):3.
  2. Penney T, Ploughman M, Austin MW, Behm DG, Byrne JM. Determining the Activation of Gluteus Medius and the Validity of the Single Leg Stance Test in Chronic, Nonspecific Low Back Pain. Archives of Physical Medicine & Rehabilitation [Internet]. 2014 Oct [cited 2020 Apr 17];95(10):1969–76. Available from:
  3. Pohl MB, Kendall KD, Patel C, Wiley JP, Emery C, Ferber R. Experimentally reduced hip-abductor muscle strength and frontal-plane biomechanics during walking. Journal of athletic training. 2015 Apr;50(4):385-91.
  4. Cooper NA, Scavo KM, Strickland KJ, Tipayamongkol N, Nicholson JD, Bewyer DC, Sluka KA. Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls. European Spine Journal. 2016 Apr 1;25(4):1258-65.
  5. MassoudArab A, RezaNourbakhsh M, Mohammadifar A. The relationship between hamstring length and gluteal muscle strength in individuals with sacroiliac joint dysfunction. Journal of Manual & Manipulative Therapy. 2011 Feb 1;19(1):5-10.
  6. van Dieën JH, Selen LP, Cholewicki J. Trunk muscle activation in low-back pain patients, an analysis of the literature. Journal of electromyography and kinesiology. 2003 Aug 1;13(4):333-51.




Articles Of The Week April 19, 2020


How often do you have a patient come in who is dealing with pelvic pain? I haven’t seen it much in my practice but I think this is also partially because it’s not common for a Massage Therapist to treat this area. Well, perhaps it’s time we change that.

“Treatment of Pelvic and Abdominal Pain for the RMT” – Jocelyn Kirton

We all know I have mad respect for Todd Hargrove, so when he puts on a master class about pain, movement, and play (while also doing it for free), I think we should all take advantage!

“Pain, Movement, And Play: Common Sense For Complex Problems” – Todd Hargrove

I haven’t had a chance to do this course myself but it was recommended by someone I have HUGE respect for, so it must be good. Another great way to get some learning done during the pandemic.

“Exercise And Physical Activity For Knee Osteoarthritis” – Rana Hinman

Still not sure where to start learning about pain? This is a phenomenal resource put together on some of the top pain resources available.

“Pain Resources: A Deeper Dive” – Rebecca Hall

We all know how important exercise is. As this review points out, it’s actually very important to help decelerate cognitive decline. Although exercise might not enhance cognitive function, it does effectively decelerate the decline in cognitive function.

“The Effect of Physical Exercise on Cognitive Functioning in Individuals with MCI and Dementia” – Scott Buxton


Looking at Pain From Different “Levels”


Pain can be a complex phenomenon, meaning that many different factors might contribute to pain, and that these factors can be interwoven in a way that makes it very hard to separate one from the other, either for purposes of explaining pain or intervening to treat it in some way.

This is a major theme of my recent book Playing With Movement, where I argue that complexity science has many concepts that are useful in understanding movement and pain.

One of these concepts is that complex systems are often nested. That means the system as a whole is composed of smaller subsystems, which are also composed of smaller subsystems and so forth.


Example of pain complexity

Where is the pain?

For example, people are made up of organ systems (like the nervous system or musculoskeletal system), which are in turn composed of organs (like the brain and spinal cord, muscles, and tendons), which are composed of cells (like nerve cells and muscle cells) and so forth. Further, people are parts of larger systems like families and communities and economies. This is interesting because each nested system provides a different level from which we can attempt to explain and treat pain.
Here’s a diagram to illustrate:
Screen Shot 2018-05-11 at 7.17.42 PM.png

At the “lower” levels, you can analyze the health status of cells and organs like muscles, tendons, discs or nerves. For example, maybe your foot hurts because of a stress fracture. This is where you can find “issues in the tissues”, which is where traditional pain treatment has focused most of its attention. This is often called the “biomedical approach” or the “bio” part of the biopsychosocial model. You find the structure that is damaged and work to repair it.

At the “higher” levels of analysis, such as the person or the environment, you are looking at more complex phenomena – the role of thoughts, emotions, or social relationships. These are the “psychosocial” issues that are known to have very important effects on chronic pain.

Problems in these areas are often relatively subtle, more about dysregulation or imbalance than something being broken or injured. These issues are also invisible if you look for them at a lower level. For example, you can’t see catastrophising by assessing a foot – you need to talk to a person.

Fields Of Study

There are many different formal disciplines you could study to get a better understanding at each level. Note that they are very different from one another, and very few people will have significant knowledge at more than one level.

Screen Shot 2018-05-11 at 7.19.35 PM.png

At the lower levels, you could study biomechanics, exercise physiology or neurodynamics. Each would give you a better understanding of how physical structures in the body respond to stress – either by breaking down and getting injured or adapting to get stronger.

You could move up a level to study the behavior of a larger system like the nervous system, immune system or endocrine system. This would help you see that pain functions like an alarm. The nervous, immune and endocrine systems help set the sensitivity of the alarm, and determine the kinds of events that cause it to go off. “Pain science” is mostly education in the basic physiology of these systems as they relate to pain. 

We can move up another level to the “person”, where we are studying the role of cognitions and emotions in pain. This is the realm of psychology, the relevance of which should be obvious – pain is a psychological event.

Psychological concepts can be very useful in understanding why movement and physical activity help with pain. For example, cognitive behavioral therapy can explain how exercise might extinguish fears or expectancies that contribute to pain. In many cases, this perspective is more helpful in choosing an exercise program than one focused on “lower-level” concerns about muscle groups, reps, and sets.   

You could move yet higher to study the role of social and economic systems. Many social critics argue that the real pathologies causing a wide variety of chronic diseases – including drug addiction, anxiety, depression, and even chronic pain – live more at the level of society than the individual. For example, low socioeconomic status is a big predictor of chronic pain. Most readers of this blog are not active in trying to solve problems at this level but are quite aware that they have a big impact on clinical outcomes.

Comparing The Different Levels

The terms “high level” and “low level” don’t reflect any value judgment. They merely indicate different perspectives: one is taking a “micro” view of relatively small and simple things like tendons or muscles, and the other is taking a “macro” or big picture look at larger complex things like nervous systems and emotions.

In general, if you’re moving down levels in your effort to explain some problem, you could call that “reductionist.” And if you’re moving up, that might be called a more “holistic” or “systems thinking” approach.

Screen Shot 2018-05-11 at 7.37.06 PM.png
Again, there is not necessarily any right or wrong here – the right level depends on the context.  Some problems with pain, especially those related to acute injuries, benefit from a lower-level approach – strengthen this, stretch that, do X sets of Y reps for Z weeks and then you will be fixed. Other pain problems can never really be “fixed” and may be hard to manage even with a whole team of psychotherapists, social workers, and attorneys.
Although each end of the spectrum has its costs and benefits, there is no doubt that until very recently, manual and movement therapists have spent way too much time at the lower levels, looking for issues in the tissues with their microscopes, while ignoring some very real big picture human issues sitting right in front of them. If the “pain science revolution” means anything, it is trying to improve basic literacy at the higher levels. “Playing with movement” means exploring a problem from as many different levels and perspectives as possible. To put it simply, finding physical activities that are challenging, meaningful and variable will go along way toward engaging us on almost any level that matters.

[REVIEW] Why We Sleep: Unlocking the Power of Sleep and Dreams


After being in PT for almost 20 years, I’ve spent the last 5 years looking at methods outside of traditional physical therapy and patient education. Everyone is searching for the elusive magic bullet that will help the non-responders. That is why I started studying mindfulness, nutrition, and sleep. I’ve touched upon sleep here before.

I’ve known that sleep is vital to recovery, for athletes with recurrent injuries, and is associated with individuals in chronic pain. So I wanted to dive into the why. I often educate my patients on the importance of sleep but did not have the background on the mechanisms of why sleep is so vital.

After reading Why We Sleep: Unlocking the Power of Sleep and Dreams, I’ve become convinced that of all the basic pillars (Sleep, Nutrition, Exercise), Sleep may be the most vital and often ignored.

How this Book Can Help Your Patients

Decreased sleep less than 8 hours on average can lead to

  • persistent flight or fight mechanisms – increased levels of cortisol
    • this was the most AHA moment I’ve had while listening to the audiobook on Audible, as poor sleep quality/quantity has been associated with persistent pain states and central sensitization
  • decreased athletic performance, increased likelihood of injury and delayed recovery times

Learning these vital points and learning about their specific mechanisms will only strengthen your patient education.

How this Book Can Help You

I purchased the audiobook and ebook in order to learn how to better educate my patients.  I also got A LOT out of it for my own health and recovery. Turns out my “I can get along with 6 hours of sleep a night” would put me in a less than 5% of the population with a rare genetic profile. I’ve been getting 8 hours a night for about 5 weeks. Similar to when I went mostly plant-based, I’ve had
  • increased energy levels
  • better recall – which honestly I just blamed on getting older and having an army of children
  • better ability to concentrate and increased productivity
Reading this text has been game-changing for me, in the same way, changing my entire nutritional profile has. The audiobook, in particular, is narrated excellently by Steve West, who has an accent on part with the Headspace app guy.
The author, Dr. Matthew Walker, breaks down sleep in a way accessible to everyone, and not just clinicians. It’s highly recommended and at the Top 5 of my Non-PT related books that everyone needs to read.
For this review, I purchased the Audiobook on Audible with my own funds, but the links to the book are Amazon affiliate links. If you purchase either with the link, you are supporting our blog. Thanks ahead of time if you do! Next step, get the author on Therapy Insiders Podcast!
Check it out on amazon!

How Watching An Evidence Based Doctor Helped Me Learn About FAI

An athlete came in experiencing some groin/adductor pain after the game.

I chatted with them a little bit and got them on the table. I did FABER’s test which resulted in a negative, but figured I would do a bit of massage to calm things down.

Then from behind me the doctor (who is much smarter, and more experienced than I am) came up and asked what was going on, so I explained what I had found.

She then asked, “oh did you try FADIR’s test?”.

I stood there looking like a deer in the headlights because I couldn’t for the life of me remember that test, I felt like an idiot.

So she grabbed the athlete, did FADIR’s (flexion, adduction, internal rotation of the hip), got a positive and then looked at the joint with a portable ultrasound machine and determined there was a possible FAI.

FAI stands for Femoroacetabular Impingement and to this point in my career had never encountered it (that I know of), so I just sat back, watched, and learned.

Femoroacetabular Impingement What Is It?

So what exactly is this anyway?

It can be defined as an abnormal bony feature of the acetabulum or femoral head or both, that leads to abnormal joint contact and stresses with deep flexion and rotation movements.  This can also lead to labral injuries, and has been related to osteoarthritis of the hip.

This can be further broken down into three different classifications:

  1. CAM type impingement – anterolateral or lateral femoral head-neck junction or the entire femoral head is prominent (the femoral head isn’t perfectly round).
  2. Pincer type impingement – acetabulum presents general or focal coverage (there is excessive coverage of the femoral head)
  3. A combination of both of the above.

This usually effects young and middle-aged active people and presents with groin pain and no history of trauma to the area. It is quite commonly seen in young athletes and has been proposed there is a possibility of gender differences which contribute to the issue. One study showed that males had less ROM with internal and external rotation when the hip was flexed at 90° as well as internal rotation with the hip at 0° of extension. But the presence of a positive FADIR test was pretty much the same for both genders. 

However, athletes who had a positive test did have greater external rotation with the hip at 0° extension than those who tested negatively. Athletes also had a higher prevalence of positive tests in asymptomatic people compared to our general population. 

There is also some discussion around physical or activity impairments and one systematic review set out to see which impairments are prevalent. They found the main issues were with range of motion (particularly with movement toward impingement, basically the FADIR test) and showed that pain likely played a role in this compared to the asymptomatic group.

When looking at the asymptomatic group, they had reduced ROM as well,  but this is likely due to bony impingement, or damage to the surrounding soft tissue and even suggests that 35% of young adults have asymptomatic FAI. 

Hip ROM when walking was also called into question but the review pointed out the amount of reduction is of little clinical relevance. The only other significant issue with movement was with squatting which could be due to the shape of the hip and pain avoidance strategies.

FADIR  is quite often used to detect pain in the hip however it’s a good test for detecting sensitivity but is not very good for specificity (60% and 52% in youth hockey players), which results in a lot of false positive outcomes. It usually elicits groin pain when being performed, some studies have shown there to be lateral hip and buttock pain as well. 

So, part of the issue with this test is the prevalence of a positive test in asymptomatic people. For this reason it can only be used as a screening tool and has to be coupled with some medical imaging to get a proper diagnosis. One study also shows that in addition to imaging, symptoms, and reduced function have to be key aspects of a diagnosis. Fortunately, the doctor in this story had imaging done, the athlete presented with symptoms and reduced function, so the doctor checked all the boxes to get a proper diagnosis (which is great to see an evidence based practitioner at work especially since diagnosing is out of my scope). 

Surgery Or Treatment?

The indication for this is usually surgery, but there are some things to take into account.

One study set out to determine if conservative treatment could be effective (although it was based on “mild” impingement). To do so, they put patients through four phases of conservative treatment:

  1. Avoidance of excessive physical activity and use of NSAID’s during an acute attack.
  2. Physiotherapy and stretching for hip external rotation, abduction, extension, and flexion.
  3. Performing ADL’s with reduced ranges of motion in internal and external rotation.
  4. Modifications of ADL’s with running and cycling (some avoidance or altered movements when not avoidable).

With the study the authors had some reasonable success with the goal of conservative treatment to be a reduction in hip pain, and avoiding further cartilage damage without reducing ADL’s. However, the results were only good if the patients could modify ADL’s so the hip could adapt. 

Another interesting point is while it was commonly believed that FAI would lead to Osteoarthritis of the hip, one analysis showed that 82% remained free of OA for 18.5 years, some up to 19 years and to date there are no studies that actually show this progresses to OA of the hip. Some surgeons even suggesting surgery is happening unnecessarily.

One systematic review showed that surgery had been the most successful, but it was also necessary to look at the reasons why people were electing for surgery. The main reasons were:

  • 33% was to alleviate pain.
  • 20% feared the condition was getting worse.
  • 16% hoped to improve ADL’s.
  • 11% due to failed non-operative treatments.
  • 10% hoped to improve for sport.
  • 10% other reasons.

So the review showed many asymptomatic people have abnormal imaging, so it is important to “treat the person not the x-ray.”

It also showed that 50% of people are overly optimistic about the surgical results and improvement, but since this does not necessarily equate to “feeling good,” it is necessary to take psychometric properties into account.

With all we know nowadays around the biopsychosocial aspects of pain, when we look at this list above, how can this change the way we’re helping people with this condition? Well, first we want to make sure every aspect of a diagnosis is done. Next we can look at ways help alleviate pain, but also build up the patients resilience and provide reassurance that the condition is probably not going to get worse (well at least for 18-19 years). Can we change up their ADL’s enough that they’re still doing the things they enjoy, but maybe just in a different manner, frequency, or intensity? In the case of the athlete, is there a guarantee that surgery will improve them for their sport? For the athlete, this may be the one area where a surgery might be necessary, but let’s take into account every option first. And as suggested, let’s make sure we treat the person, not the X-ray.

I will admit, that while I felt like a bit of an idiot when this happened (because I wasn’t familiar with the test and FAI in general), it was a GREAT learning opportunity to watch someone with more education, more experience, and let’s face it smarter than me do their work. Fortunately the doctor was pretty gracious in sharing her knowledge with me, and it made me look at the research on this and write this blog…so I learned a lot.