Summary

To evaluate whether preoperative measures of pain tolerance and grit influence the presence of hip-specific symptoms, opioid consumption, and outcomes in patients with FAI syndrome that undergo arthroscopic hip preservation surgery.

Abstract

Background

Femoroacetabular Impingement Syndrome (FAIS) is a common cause of hip pain. However, not all people with cam or pincer morphology experience pain. The exact reason for this is incompletely understood, but pain perception, pain tolerance, resilience, and grit may offer potential non-musculoskeletal explanations. To evaluate whether preoperative measures of pain tolerance and grit influence the presence of hip-specific symptoms, opioid consumption, and outcomes in patients with FAI syndrome that undergo arthroscopic hip preservation surgery.

Methods

The present study is a prospective comparative cohort study. The patient population includes individuals with FAIS scheduled for hip arthroscopy (labral preservation, cam/pincer/sub-spine correction, capsular closure) with a single surgeon fellowship-trained in hip preservation. The control population includes healthy volunteers. This study includes 47 FAIS patients (16 female; mean 36.4 ± 10.2 years of age) and 48 healthy volunteers. Briefly, healthy volunteers completed all study activities in a single timepoint, while FAI patients completed surveys at multiple timepoints. All study participants underwent a one-time cold pressor task (CPT), immersing their hands in a cold-water bath (0.22-2.78C) for a minimum of one second and maximum of 180 seconds. Participant pain (VAS 0-10) was assessed periodically during the CPT and participants were blinded to the time limit. Surveys assessing grit, pain perception, catastrophizing, kinesiophobia, and other psychosocial behaviors and attitudes before surgery were completed. Subjects were dichotomized into three groups: Group 1 (CPT of 180 seconds), Group 2 (CPT 45≤x<180 seconds), and Group 3 (CPT <45 seconds). Descriptive and comparative statistics were performed.

Results

Prior to surgery, no significant (p>0.05) differences were observed between age, sex, body mass index, average pain level during CPT, or time spent during CPT between surgical patients and healthy volunteers. Seventy-nine percent (37/47) of patients self-reported a high pain tolerance before surgery, while 65% (31/48) of volunteers self-reported a high pain tolerance. Fifty-one percent of patients (24/47) had a CPT of 3 minutes, while 50% of volunteers (24/48) had a CPT of 3 minutes. Patients had significantly (p<0.001) worse AFAQ (Athlete Fear Avoidance Questionnaire), PCS (Pain Catastrophizing Scale), and TSK-11 (Tampa Scale of Kinesiophobia) questionnaires than HV. Males demonstrated longer immersion time (134.1±0.1 versus 98.4±0.1 seconds). Thirty two percent (15/47) of patients had CPT less than 45 seconds. Seventy-three percent (11/15) of these Group 3 patients with objectively low pain tolerance self-reported a high pain tolerance. Patients in Group 3 took more than double the amount of hydrocodone (39.4% of pills taken within two weeks following surgery) than Group 1 (19.3%).

Conclusions

Most subjects that underwent hip arthroscopy for FAIS self-report a high pain tolerance (79%), which is a statistical improbability (illusory superiority via Dunning-Kruger and Lake Wobegon effects). Nearly one-third of patients (32%) had a CPT less than 45 seconds and within that group of 15 low pain tolerance individuals, 11 (73%) self-reported a high pain tolerance. Clearly, pain perception is a highly subjective variable that requires meticulous surgeon interpretation in hip preservation surgery patients. Clearly, if patients claim they have a high pain tolerance, they probably don’t.