Case Study: Crossfitter Hip Labrum Tear

There are too many abstract discussions in the performance space these days about how to train and rehabilitate athletes.  These circular arguments usually yield nothing substantive or actionable because providers spend too much time defending their ideology and trying to articulate why they are in the right instead of just being transparent and “showing their portfolio”.  As an example, investors should demand that financial advisers share their own portfolios instead of pontificating about macroeconomic theory. Words matter but what people do when they have skin in the game reveals more about them than their explanatory justifications for said actions. 

The point of these case studies is not to suggest that what we did in any of these situations is particularly good.  If we’re being honest, we don’t always have robust outcome measures to suggest that what we do really “works”. More often than not, we default to the eye test.  We coach and own our decisions. The intent here, therefore, is to be completely transparent about what we did when an athlete’s time, money, and readiness was at stake in hopes that other providers share their experiences and contribute to a more genuine collective conversation. 

Background

Female recreational athlete with persistent “stabbing, sharp” left groin pain whose primary objective was to participate in Crossfit and group fitness classes without symptom provocation.  She had been completing said classes despite the pain but modified exercises that irritated her hip. She claimed that the cascade of hip pain began when she hit her shin completing a box jump during a Crossfit class, a mechanism of injury that didn’t seem to explain the medical diagnosis she received.  After undergoing physical therapy without much perceived improvement for almost a year, she was referred to an orthopedist for a consult and MRI. The MRI revealed a labral tear and because the patient hadn’t progressed with PT she was scheduled to undergo hip arthroscopy a week after her initial evaluation with us.  She scheduled an evaluation with us after her Crossfit coach, with whom we share a facility, recommended she do so upon hearing about her impending procedure.  

Constraints

• Time: Seven days until scheduled surgery. 
• Logistics:  No factor
• Financial: No out of network benefits so patient paid out of pocket. Patient was willing to pay whatever was necessary to avoid the surgery.  Her insurance carrier previously covered a year of in network physical therapy and would have covered the majority of the surgical cost.  
• Interpersonal Factors: Patient was frustrated and seemed to accept the inevitability of surgery.  She said she’d consider an alternative course of action contingent upon her progress during the initial session.

Evaluation Findings

• Pain with unloaded deep squat, stopped at 90 degrees
• Palmed the floor on toe touch without visible reversal of her lordosis
• Orthopedic testing/gross movement: limited hip extension bilaterally (↓L), limited hip internal rotation L, limited hip adduction L
• Labral tear revealed on MRI but no detectable instability/catching/locking on clinical exam
• Ultimately, objective and subjective findings normalized after 1st session.  Prior to going home that day, the patient performed various forms of loaded squatting (goblet, kettlebell front, barbell front, barbell back) in a pain free manner.  Patient was asked to consider cancelling the surgery. Plan after session 1 was to perform a more aggressive strength training session during a follow-on visit that better simulated the patient’s group fitness classes to gauge readiness.  Session 2 occurred four days after session 1.
• Patient completed session 2 without symptom provocation and was told to perform that sequence of exercises 2x/week along with the exercises from session 1 on non-training days and as a warm-up on training days.  She cancelled the surgery after the second session. She was also instructed to continue with group fitness classes 2x/week for 2 weeks and add a class every 2 weeks until she was completing 4/week. At 4 weeks she was instructed to do whatever she wanted class wise but to continue to complete the session 1 sequence a few times a week for maintenance.  

Plan of Care

• Session 1
  • Glute Bridge Iso Hold - 2x30-45s, squeeze pilates ring
  • Hip Shift Hamstring Bridge Reps - 2x10, only side shown in video
  • Counterweight Squat - 3x30-45s, no counterweight, squeeze pilates ring
  • Bench Side Plank Extended - 2x30-45s, choke up on bench as needed
• Session 2
  • A1) Double Kettlebell Front Squat - 3x5-6, 4s lower, blue kettlebells, feet shoulder width or slightly narrower
  • B1) Glute Ham Raise - 3x6-8, partial range of motion, don't arch back or fold at hips, keep hips through
  • B2) Split Squat Iso Hold - 2x40-60s/side
  • C1) Chair Sit Holds - 2x good form
  • C2) Ball Rollout Bear - 2x6-8, tuck/round hips