Thoughts on martial arts injuries pre labral repair

For the last several years, I've had some on-again off-again low back pain variously diagnosed as sacral-iliac (SI) instability, or lumbo-sacral (LS) instability.  So every year I go into PT for a few weeks, straighten things out and go on with life.  This time, it was pretty clear there was a deeper root cause, and a couple of months ago, I was diagnosed with a labral tear of the left hip. By this point, everyone involved (PTs, doctors, etc) realized that the tear had been the cause of the other symptoms and that something more than physical therapy was needed to straighten things out.  An arthrogram MRI and orthopedic consult later, I was scheduled for surgery to repair the tear.

Figure 1: Looking up the leg.  The tear is the thin disconnected section on the lower left of the hip joint.

How common is this injury among athletes?  Fairly common, although it's difficult to get percentages.  Athletes who are involves in martial arts, running, dance, gymnastics, and yoga are often at risk for such injuries.  What's in common?  Either an extreme range of motion or a repetitive range of motion.  The thigh bone may then contact the outer portion of the acetabulum (hip joint socket) and create either a cam or pincer lesion which then saws through the labral cartilage.  This, in turn, destabilizes the hip and causes lower back issues.

Chinese Wushu and other martial arts are known to promote longevity due to the physical conditioning of the body, yet many participants often have to leave off practice as they get older because of injuries suffered during practice.  The two ideas are a bit hard to reconcile.  How is it that something that is so good for you can also be so bad?

An answer that we sometimes tell students is that you'll only get hurt if you're doing it wrong.  This should be rephrased to: "you'll only get hurt if you are doing it wrong for you."  In this age of large commercial schools, and competitions with compulsory type forms, we often try to bang students into a specific mold rather than finding the variation of our martial art that works for the student.  We also don't always recognize that at the extremes of competition, we place a great deal of stress on the body and it is very easy to get injured.  I remember an old wushu friend of mine, Bobby DeSario, telling me that when he visited Beijing, he noticed that many of the competitive athletes were favoring one leg or had a shin wrapped.  Even Jet Li has had a bad injury from wushu.  According to his official site (jetli.com), he tore his ACL during a split landing from a tornado kick. 

Figure 2: Not Jet Li, but the landing he should have had.  This position can exacerbate labral tears, if you've managed to get yourself one.

No doubt that some of the thrill of watching Chinese martial arts comes from the amazing things the players can do without being injured.  It's not so fascinating to watch punching when you can see someone do a butterfly twist into a split.  But you don't get something for nothing.  The more spectacular the move, the greater the risk, and the more chance you have for ending your career early.

So what is a coach to do?  Do you teach your students the fancy stuff but tell them to be really careful?  Or do you take the other extreme and tell students to stick with the traditional stuff: don't do particularly low stances, and limit jumping?  My thinking is that you take the middle road. 

1. Teach basics bilaterally including jumping.  This will keep the body more symmetrical and limit progressive instabilities in the musculature.  Knowing techniques on both sides might also be useful from a martial arts viewpoint...
2. Use the usual principals of progression in training.  If a student isn't strong enough or flexible enough, don't let them do the activity.
3. Teach students how to listen to their bodies.  Do reinforce the idea that they are not immortal, and a bit of down time now may save them a lot of down time later.
4. Log and limit high stress techniques (tornado kicks, splits, lotus kicks, twists, aerials...).
5. Despite your best efforts, a student may not be able to do a motion in a certain way due to physical limitations.  Some people (for example) have an acetabulum that will not allow for a split.  Present your students with sane alternatives to the flashier movement.

Point 4 is probably really controversial in wushu circles, partially because of the ("if you do it right you won't be hurt" mentality).  However, pitchers at the upper levels (high school, college, minor leagues, major leagues) all log the number of pitches they do.  In fact, they even do this logging in little league, and the results are pretty clear: "The risk factor with the strongest correlation to injury is pitching." (Fleisig & Andrews, Sports Health. 2012 Sep;4(5):419-24.)  This study does support the idea that there is a right way and a wrong way to pitch.

Considering the numbers of high kicks, and impact loading due to landings from jumps that occur in  our sport, not logging activities is asking for trouble.  Even when done correctly, repetitive loading on a joint or structure can cause problems. For my own part, I have not logged my own practice, although as I've gotten older, I've been better at listening to my own body.  I don't jump so much as I used to (and right now, not at all), and when I do jump, I do the bare minimum.  How then did my labral tear occur?  It's a good question.  I'm in a couple of the aforementioned risk groups.  It could be repetitive motion.  I also have had a number of groin injuries in the past.  These can temporarily (or permanently!) reset pelvic tilt and pre-dispose you to a labral tear.

In any event, I'm now looking forward to hip surgery in two days so that I can run, jump, and kick high again, just not in the near term.  Recovery will take 8 weeks to full return to activity, subject to not overdoing it after the break.  In the meantime, I'm looking forward to figuring out my crutches to determine the most efficient ways to move without stressing the hip (Crutch-fu).  And I'm looking forward to learning how to better coach from the sidelines while I'm recovering.  See you on the other side.