(update: I finally got surgery five years later. I’m six months post-op. I think I might be somewhat better, but it’s hard to know for sure. Either way, I’m glad I did it so that I know I’ve tried everything I can.)
It was a bad omen—the sign outside the hospital parking garage read, “6′4″ maximum height”, three inches too short for me.
The pain in my hip started a couple years ago. It had gradually gotten worse to the point where I could hardly walk. Despite being well versed in the experience of muskulskeletal injuries (tall people tend to be), I was particularly impressed by just how disabling a hip injury can be. Looking back, I’m certain that cycling was the main culprit. Counterintuitive, you might say, given cycling is so often recommended for those with ailing hips. But please read on…
I saw a sports medicine doctor who ordered me an MRI. Only minor arthritis turned up. The real problem was something commonly referred to as femoroacetabular impingment (FAI) as well as a labral tear. My doc referred me to Dr. Olufemi Ayeni, an orthopedic surgeon in Hamilton. The wait time to see him was about a year.
FAI has only become a recognized, diagnosed, and treated pathology in the last couple decades1. FAI is essentially when the acetabulum and femoral head (ball and socket joint) do not mate up ideally because of a geometric irregularity, such that end range of motion is limited and impingement of the soft tissues results. The two types are in the figure below. I have the cam variety.
The pressing question is, how does one acquire FAI? We all begin with pretty great range of motion as babies, right? One possibility is that physeal (growth plate) stresses cause deformation2. It would follow then that tall people are at increased risk of FAI given we experience greater stresses as per the square-cube law. Yet I found no mention of height in my search of the literature, so no way to verify this.
Ergonomic issues make FAI particularly problematic for tall people. For instance, sitting in too low of seats forces the hips into greater flexion. This is worst in cars where tall people actually lower their seat to get more headroom. For me this was even worse as I had actually modified my car seat to make it go even lower! Also, tall people may have a greater tendency to sag into one hip while subconsciously trying to reduce their stature for low work surfaces, conversations, etc. Out of all the issues though, for me, cycling was the biggest. And ironically, this was made worse by my extra long 200mm cranks.
FAI has been implicated in the early onset of osteoarthritis. It can be treated conservatively with physiotherapy and/or injections, or surgically, either open or arthroscopic. The state-of-the-art arthroscopic procedures focus on repairing the soft tissues and shaving away bone to reshape the joint geometry for greater congruity, thereby permitting full range of motion of the hip joint without impingement. But the problem with this kind of surgery, much unlike total hip replacements, is that the soft tissues take a very long time to heal (one estimate I heard was six months). I decided I would try to manage it conservatively. What gave me confidence was that there are a lot of asymptomatic people out there walking around with FAI and labral tears.
The first step for me was to remove the exacerbating activities. This meant stepping back from cycling. What cycling I eventually got back to I did with standard length cranks and in a more upright position—I also built myself a tall ebike so I could still get around without my car. As far as the sitting issue, I try to get work done from other positions (see my sit-stand zero gravity workstation setup). And at the gym, I avoid any kind of deep squat or lunge. I also make an effort to place even weight on both legs.
Besides removing the cause, there are some exercises that are supposed to help. Specifically, strengthening of the glutes and stretching the hip flexors is supposed to decrease the load on the anterior rim.
Nearly a year later, I finally got to see Dr. Ayeni. He was quite friendly and helpful. He confirmed what I already knew and provided more detail on the condition. He let me know I could continue to treat it conservatively, or, he could operate arthroscopically. I was doing much better by this point and decided to continue without surgery. However, even if I did want surgery, he would need special clearance to operate as I exceeded the maximum recommended height of 6′6″ for the operating room (ORs are typically designed for 5′10″ males). Shocking, but at least it’s an improvement over the parking garage.
Update: I saw Dr. Ayeni another year later to ask some more questions and keep my foot in the door. One of the questions I had was whether it would be a quicker recovery if he just fixed the torn labrum, leaving the geometrical deficiency alone for me to deal with. The answer was no, as the healing bottleneck is the drilled holes through the muscle. Curiously though, he happened to be involved in a pilot study at that very time to investigate the outcome of exactly what I suggested. Personally though, if healing time is the same, I would want to get the full deal done. It’s a moot point for now though, as I continue to have success with my conservative approach to managing it. Whether the osteoarthritis is building up though… only time will tell. If I ever were to get surgery, I would trust Dr. Ayeni to do it.
- M. Leunig, P. Beaule, R. Ganz, “The Concept of Femoroacetabular Impingement: Current Status and Future Perspectives“, the Association of Bone and Joint Surgeons, 2008.
Physeal injuries in children’s and youth sports: reasons for concern?
More reading, a good opensource article: Femoroacetabular Impingement
Interesting article and spot on for me. I’m close to 6’6″ and was an avid cyclist a couple years ago with 200mm cranks.
Do you have anymore context on why longer crank arms would be bad for tall cyclists? I thought it would be a more natural fit. However I did usually a feel a tightness in my hips from riding.
I use to play a lot of basketball but left that for cycling for lower impact.
I started a gym routine three months ago and hit the stair climber really hard one day and since then I’ve started getting pinching in the front of my hips and seeing a PT about it. He gave me some good exercises that seem to be working but cause discomfort the following days.
For me, the extra bone laid up on the neck of my femur (probably from extra mechanical stress during my growth spurt) would contact my labrum (pinch) when I brought my knee up to hip level (90 degree hip flexion). Regular bike cranks didn’t result in this, but extra long ones did. So with my extra long cranks I was repetitively pinching the labrum and eventually tore it.
I finally got surgery to remove the extra bone and fix the labrum. I’m about 5 months post op and am supposed to peak around 6 months. In some ways I do feel better but it’s definitely nothing dramatic.
Hips are very precious. We need them to allow the largest muscles in our body to work and keep the heart healthy. There are hip replacements but I’ve been told it’s not good to play that card to early in life. So best take care of the hip joints best we can! For me, that means no activities with a lot of impact, not sitting at 90 degrees or more for too long, and only cycling in an upright position with the seat nice and high. I also do my physio exercises diligently every evening. Eliptical machines seem to be an okay way for me to get cardio still. But when my hip is bad I just use an arm bike.
Pain a day later sounds bad. Find a physiotherapist well versed in femoral acetebular impingement. Mine is actually hooked up with my surgeon who specializes in FAI. Let me tell you there is a big difference between that and some random phsyiotherapist.
I had both as well plus bone on bone arthritis. The pain got so bad, I had a total hip replacement April 2019. I used a road bike back in the 1980’s in my youth for long distances, but did not know anything about ergonomics and my height (6′ 6″) since I felt like superman. I never knew about impingement, but was never able to sit with my knees together, feet flat on the floor or cross my legs in any way. I man spread! Today with all the people crying over man spreading, I say tough. Even with the new hip I cannot keep my legs together. But hey I’m 60 now. I will say to keep doing the physical therapy they gave you as part of your daily /weekly excersize program. It really helps with the muscles around the joint. I do not know your age, but I can say to do what ever you can to keep the weight off. I went from a smoker in the 70’s and 80’s and still into sports, (football and running 10k’s, killed my knees and my hips and basketball, baseball/softball killed my ankles) and my weight was 165. I looked like I could hide behind a telephone pole. Now though I sit at a desk for the last 25+ years all day and my weight went up to 365 pounds. making my joints hurt even more.
Thanks for words of encouragement.
One would think that if we all knew that being tall put us at risk of injury if we wouldn’t have pursued sport so vigorously. But I think we probably would, it was such a huge part of my development and joy in life.
I’m 215 lbs at 6’7″, so not a bean pole exactly but still slim. Having always been slim, it’s hard to imagine I would ever gain weight, but stories like yours make me realize all our bodies change. I do know though what an extra 40 lbs feels like though as I take my 45 lb son on long hikes (yup, before FAI surgery I couldn’t have done this).
I hope you can find a way out from behind the desk. I’ve been thinking of maybe trying pickle ball as that looks pretty easy on the joints. Otherwise, I alternate between the elliptical, super upright stationary bike, and an arm cycle to get a bit of cardio. And swimming when the pools open back up!
Man spreading, lol!