Wednesday, August 31, 2011

Running with a Hip Labral Tear - Avoid / Postpone Hip Arthroscopy

Running with a Hip Labral Tear –Avoid Hip Labral Tear Surgery

After developing a set of symptoms consistent with a labral tear, I spent some time reading online running forums. I got the feeling that I am not alone in being very frustrated with a likely diagnosis of labral tear and being very motivated to continue with the running that I have grown to love (and am quite possibly addicted to). With that in mind, I wanted to share my experience in the hopes that it might help other runners facing a diagnosis of hip labral tear get back to doing what they love, even if it’s modified a bit. So with that, let’s dive into my history.

I was half way through my first marathon training program and making phenomenal progress (gunning for a Boston Qualifier on my debut) when during a tempo run I experienced some pain in my left hip. This was on perhaps a Tuesday before my first big tune-up race, the Drake Half Marathon. I ran this relatively hilly race with a pace of 6:31. I was proud of my progress (I was running a 7:30 5K a year or so before but had made major strides by implementing a combination of Chi Running and Evolution Running and dropping 35 pounds through the Standard Process Purification Program and overall improved diet) but aware that my hip felt worse by the end of it. My training plan from Advanced Marathoning by Pete Pfitzinger called for a 20 mile run the next day so I went out to do it. My hip got worse over the first 3 miles to the point where it was giving me a sharp stab deep in the joint radiating to the groin with each step so I stopped and walked dejectedly back to my car. I stopped running for 2 or maybe 3 weeks while I aggressively stretched my hips and focused on keeping my cardio up with cycling. I focused on stretching the adductors, piriformis, and hip flexors but was aware that stretching did not necessarily feel beneficial. Being a chiropractor, Active Release Techniques Provider, and active person, I think of myself as quite in tune with the different types of pain and was aware that with the stretching I felt a “block” sensation within the ball and socket joint on adductor stretching rather than a beneficial feeling stretch of the hip flexors or adductors. With that I started looking into hip labral tears online. Quite frankly, the information on the forums was quite depressing. As a chiropractor, I am the sole source of income for my business and I was reading articles of people needing crutches for 6 or more weeks after hip labral tear surgery. That kind of time out of my practice was impossible. I considered having an MRI with contrast done to confirm the diagnosis, but came to the conclusion that it was irrelevant as it wouldn’t change my actions. I wasn’t currently interested in surgery or a steroid injection, so I would be resting my hip no matter what. With a high deductible health insurance plan it didn’t make sense to pay for a test that wouldn’t change my actions at all.

After 2-3 weeks I was walking relatively pain free so I started running again. After all, I was in the middle of a training program. On Monday I ran two miles, Wednesday - five, and Friday - seven, but when I got to 10 my hip started to give me a sharp pain again. I stopped but at that point I had aggravated the hip to the point where I was getting a sharp stab even during normal walking and while giving low back chiropractic adjustments to patients. That lasted for about 10 days. I resigned myself that I would not be doing the Dam to Dam 20K or the Duluth Marathon and tried to tell myself I enjoyed cycling and open water swimming as much as running. It didn’t work. I got my wake-up call over a Fourth of July camping weekend when hot humid weather woke me up frequently during the night causing me to remember my dreams. Normally I don’t remember them. My dreams were all about running and they were good. I was fast. I resolved to find a way to start running again.

Below is the plan I followed to get back to running. I can’t say it’s been totally successful because I’m in the middle of it. I’ll update it if I reach my goal. I do want to be clear that this is not medical advice. Running with a labral tear could certainly result in short term pain or possibly make your situation worse. Your individual situation is certainly different than mine. There’s also a possibility that you could accelerate degenerative changes in your hip. Consult your sports doctor if you have questions about any of these ideas I used.

I let my hip get relatively pain free during walking and short runs.

I had already watched the videos Chi Running and Evolution Running. For those of you out there reading this article and feeling hopeless, I strongly recommend that you watch these two videos. They show you how to minimize stress into the various parts of the body. They have many similarities but just enough differences where I really have to recommend that you watch them both and implement elements of each of them.

I recognized some goals to minimize labral tear aggravation during running. The stretches I was doing seemed to make things worse so I stopped doing them and the hip improved. This seemed to indicate that the labrum was actually aggravated by being taken through full range of motion. From the perspective of running with a labral tear, I saw three main goals. The first is to minimize the shock into the hip ball-and-socket joint. The second is to minimize the forward and backwards movement of the upper leg bone within the ball and socket joint. The third is to minimize inflammation. With those goals, I set up my rules for running.

My rules for running

a. Forward lean – I was already using a forward lean. This concept is mainly taught in the Chi Running DVD. With a forward lean you let gravity pull you forward. Your foot lands under your center of gravity as you are moving forward which prevents the major shock from traveling up your leg. When your foot strikes in front of your center of gravity (in particular with the heel first) you have a major impact as the weight of your core body is moving down and forward at the time the heel strikes. An impact shock travels up the leg when your heel strikes and would certainly affect the hip ball and socket joint. Running upright with the heel striking in front of the body can be thought of a bit as stomping on the car brake for an instant with every step. With a forward lean you minimize shock into the ball-and-socket hip joint.

b. 200 steps per minute – both the Chi Running and Evolution Running DVDs recommend a running cadence of about 180 steps per minute. This would be if you were counting both foot strikes. If you were only counting your right foot strikes it would be 90 steps per minute. I personally go beyond their recommendations and shoot for 200 steps per minute. The reason this is recommended is that speeding up your running cadence decreases the amount of up and down movement of the core body. Ideally, we’d like to see the top of your waist and your head move up and down as little as possible. A person who runs at a cadence of 120 steps per minute might have 2-3 inches of up and down movement at the hips and head. This up and down movement can be viewed as shock and stress into the hip joint as it lets the weight of your upper body crash down into the legs with every step. When I run at 200 steps per minute, I only feel my hips and head move up and down perhaps a half a centimeter. Compare your running to bicycling. Bicycling is considered low impact and efficient because on a bicycle your hips don’t move up and down at all. The second benefit of a faster cadence is that for any given running speed, it shortens your stride. This minimizes movement into the hip ball-and-socket joint. Try to use a faster cadence to minimize vertical motion of the hips and core body and to minimize forward and backward movement of the upper leg. There are many free metronome apps for iPhone and Android phones. I strongly recommend you run with a metronome all the time as you start this process. I use a iTick on my iPhone almost every time I run. I have the sounds set to cowbell so I can imagine Will Ferrell cheering me on as I run.

c. Ball of Foot (Forefoot) Strike – The Evolution Running DVD recommends forefoot strike where your heel never touches the ground. It highlights that with a forefoot strike all the impact stress is absorbed by the calf muscles, Achilles tendon, and plantar fascia. Try standing still and try to stomp the ground as hard as possible, but don’t let your heel touch the ground. Now try stomping down heel first. You’ll feel that as long as you don’t let the heel touch the ground it’s impossible to generate significant impact shock up into the hip. Forefoot strike minimizes shock but I’ll be honest, it can be a bear to adapt. At first you’re going to think your calves hate you. However, you have to remember that it’s better that your calves hate you than that screwed up hip. You have to ease into this one. If you’ve never run with a forefoot strike I recommend a very gradual progression.

d. Lift the lower leg off the ground rather than push your body forward – If you get the lean and the cadence down right, you can focus on keeping your upper legs relatively still while lifting your lower leg off the ground. This will minimize movement into the hip ball and socket joint. To integrate this, first practice running in place with a metronome trying to keep your upper leg still and just lift the lower leg off the ground. Then while you’re out for a run, pick a point in the distance and imagine a bungee cord from your chest to the point. Imagine that the tight bungee is pulling you forward. All you have to do is lift your feet and lower legs below the knees off the ground fast enough and you will move toward that point. This visualization should help you do a proper forward lean which combined with the quick cadence moves you forward and minimizes motion into the hips.

e. Day in between each run – If you’re used to running daily for fitness or to follow one of the popular running training guides, I know it can be hard to skip a day. However, I personally had to come to terms with the fact that despite all my steps to change my running style, there was still some amount of inflammation in the hip every time I went for a run. I had to be thankful I wasn’t getting the sharp pain. By leaving a day in between each run I’ve been able to build up to a consistent three to four mile run three to four times per week. On the positive side, faster seems to be less stressful on the hip so it’s not as if I’m plodding along slowly. I ran my fastest 3 mile ever on the trail recently and felt no worse for it. I’ve recently drawn up a training program that will take me up to 6 mile runs (and hopefully a sub-18 minute 5K). The training plan is based on the book Run Faster from 5K to Marathon by Hudson which is great for my situation as he recommends an adaptive training plan where you listen to your body every day, your plan is in pencil, and you anticipate that you will make changes to the plan to maintain your health.

f. Listen to your body – I am very focused on my hip. For me, mild dull aches are ok but if I feel even a hint of sharp pain, my training plan is off until it’s gone. Let’s hope that doesn’t happen.

g. Gradual build – I set out the above rules and stuck to them. If my cadence dropped below 195 steps per minute I stopped and walked. If blisters on the ball of my foot stopped me from doing my forefoot strike I stopped and walked. If I had never done any forefoot striking I would have followed the best progression for true beginners – (1 min run, 3 min walk) and repeat for the first week, (2 min run, 2 min walk) for the second week, (3 min run, 1 min walk) for the third week and progress to some short continous running. I have actually been following the rule that you should only increase your running by 10% per week. I’m trying to learn from my past stubborn foolishness and I’m very motivated to stay healthy while running.

h. Minimal shoes – Personally, I am using Vibram FiveFinger Bikilas. I find that they help me make sure that I never let my heel touch the ground. Also, they are conducive to that super quick cadence as there is no foam to slow down my foot-ground contact time. However, I do get some soreness in my feet. For people reading this, I’d consider minimal shoes like the FiveFingers but otherwise at least get some shoes with a minimal heel-toe height difference which are conducive to forefoot strike such as the Saucony Kinvaras or perhaps some Newtons.

I hope my experience and plan help you form a plan to run with a labral tear. I’m sure there are true surgical cases but I hope that my game plan laid out here keeps me running for a while and possibly forever without what I view as a risky surgery. Feel free to give feedback in the comments section.

Compass Chiropractic Website

14 comments:

David Krohse said...

Ran a new 5K PR this past weekend - 6:04 pace. Fast and pain-free. My runs have still been relatively short. One run took me up above 6 miles and I felt like the hip took a little step backward. I moved my next hard run back a day but was able to stay on schedule otherwise.

David Krohse said...

Ran the Kansas City Groundhog Run 10K with a 6:19 pace. Starting training today for Madison Half Marathon. Hoping to keep the hip healthy!

WeidnerCharm said...

After a year of not running, I ran on the grass for 3/4 of a mile. There is a small ache, but no sharp pain. I think I am ready to start again. I am really excited about trying your methods.

David Krohse said...

The foot soreness from the FiveFingers eventually became too much. I'm currently running in Saucony Hattoris. Their slogan "for those who want to run barefoot... More than once" is accurate in my situation. I like them and my feet didn't get sore in them on recent runs up into 8-12 miles.

David Krohse said...

Currently running about 26 miles per week. I'm following Run Faster from 5k to Marathon training plan 2 for half marathon but I only do the 3 key workouts for the week. I skip the recovery miles. Two intense runs around 7-9 miles during the week and then a long run of 10-13 miles with a faster finish on the weekend. I get a full 2 days off from running after my long run day. I'm going to do some triathlons this summer if my health holds up so I am trying to do 2 bikes and 1 swim day as well. If my hip holds up for Madison Half I think my girlfriend will talk me into taking another run at a full marathon - probably Twin Cities. I'm running in Saucony Hatorris and occasionally Newtons. I do all forefoot strike with my problem left hip but on longer runs get lazy and let the right leg settle into midfoot strike. Hope that funky gait doesn't set me up for some other injury! :) I post some of my runs to twitter if you're bored @davidkrohse. I didn't mention it much in the main article but I do think it becomes more important to dial in your nutrition for optimal recovery and decreased inflammation in situations like this. Personally I am taking fish oils, a whole food multivitamin (Catalyn by Standard Process), 2400 iu Vitamin D, Glucosamine Synergy by SP, and some SP Ligaplex. I try to eat 80 percent paleo - decreased grains and dairy. I generally am pretty good about getting some quality nutrition in right after my runs.

Happy running!

sjeannette said...

HI David,
I am in a similiar situation. I just got my MRI results and I have Labral Tear and impingement. I am in the process of training for half marathon but not sure if I will be able to do it! It's in Sept. I did have Cortisone injection ordered by md, which I wish I had not gotten but it did help but it was 1.5 weeks ago and the pain is coming back. I am so upset b/c my personal goal this year was to do my first half and I don't think I can do it. Surgery is the plan but I wanted to wait until after the half. I hope that I will be able to do my lifetime personal goal!!!
Do you plan to have surgery? Does your back have pain too? Mine does but not sure if it's related. I am happy to have found your story. Good luck! :)

David Krohse said...

After following the plan I laid out I am running without significant hip flare ups for now. I ran the Madison Half Marathon in 1:26 over Memorial Day Weekend.

Sjeannette, as a chiropractor and Active Release Techniques provider I would suggest finding a fully certified Active Release chiropractor in your area to see if some conservative care might help. Tightness of the psoas/hip flexors is a likely culprit for hip and low back pain. Good luck!

Sharpie Fish said...

Hi David,

How are you feeling after running so much with labrum tear?

I have labrum tear since 2004. I am not willing to get the surgery. Running had given me pain if I wore regular running shoes. I feel little or no pain running or taking long walks in Vibram Five Fingers KSO. Still I choose not to run to avoid risk of high impact. I swim instead.

David Krohse said...

Hi Sharpie,

I try to make my running as low impact as possible, by using the strategies outlined. If my hips don't move up and down at all, then that decreases a lot of impact. If I take small steps, that decreases impact. If I keep my center of gravity forward by leaning forward, then I never "stomp on the brakes" like normal long stride with a heel first strike causes. By running this way I haven't aggravated my hip. This year it's my ankle that's screwed up... Gotta love running :)

Emily de Lacy Donaldson said...

Hi David,

Thanks for the awesome post on your experience with a hip labral tear. I was just diagnosed with a hip impingement (possible labral tear). I am trying my best to stay positive about non-surgical recovery, but most people out there had surgery.

I am now 3 months out from Boston, with Big Sur on my schedule two weeks after Boston. My endurance is high since I've been swimming a lot, but my mileage is very low for usual marathon training. I can't run without some sort of ache, even if it is slight. I've been getting regular ART, sports massage and now, just started a strength PT program.

My questions are: I feel like I am improving, extremely slowly, but improving - did you have a very slow improvement of your symptoms or was it quick once you changed your gait etc? And, did you continue to train lightly with the dull ache/little twinges? Did they eventually go away? I had psoas release work done and the sharp pains disappeared, so now I'm dealing with daily dull achiness and strange feelings, but nothing as bad as it once was.

I'm starting to lose hope that I can beat this without surgery, but with my current professional life/lifestyle, surgery doesn't seem to be a viable option.

Any experience you can share would be so helpful!

Jessica Castro said...

I was diagnosed with right, intertrochanter stress fracture a few months ago as well as a right anterior labrum tear. The tear has become the bigger issue. I was training and pretty much ready for my first half marathon when this happened. I found your article very helpul. I have been swimming a lot and you have given me a plan to try since I am dying to start running again. Thank YOu

David Krohse said...

Finally ran my debut marathon in Des Moines in 3:04.26. My hip wasn't a problem but my training has been far different than standard marathon training. I probably averaged 20-22 miles per week through the summer. One longer run each week of about 14-16 miles, some with a fast finish. One or two 6-8 mile runs during the week. Then I do a recovery pace run with my girlfriend at 9:45 pace on the weekends. I got addicted to using Strava and so my intense training was segment hill climbs and segment sprints on the bike. I'm probably done with marathons now

Odyssey Woman said...

Diagnosed with FAI and labral tear in February of this year after running first half marathon. Did PT. Surgery was recommended. Did not run for 10 mos (Nov-Sept). Started back with run/walk and made recommended changes. I'm pain free. May not run big distances again, but at least I'm out running 2-3 miles 2-3 times a week.

Jenny said...

Hi David! I am very happy to hear you are doing well running with your tear. I had an MRI done a little over a month ago and was diagnosed with a hip labral tear also. It felt like my world shattered; all the doctor would tell me is I need the cortisone injection and eventually surgery. I do not think surgery is the way to go for me but I miss running so incredibly bad. I was training for a half when this happened (ran too many hills and used the thigh master type machine with too much weight). I have thought about going to a chiropractor who specializes in ART to see if that would help. Is the running not causing your hip more damage? I would be happy if I could get back to just 3 miles a few times a week...swimming has been alright but nothing beats running!