Treatment of Shredded Cheese of the Hip: A Case Report and Rant

A Long Day

I officially eclipsed my longest work day ever. Started seeing patients at 7:30 am and finished training my last client at 10 pm.

So exhausting, but the bright side is my new schedule prevents me from waking up that early ever again! Hooray for sleeping in…sort of.

I figured while I had some time in the airport before my next course, I would write a little something about a patient I evaluated right before my lunch break on this long day. Needless to say, I didn’t get much of a break.

Her Story

This lovely lady is a nurse with a history of chronic left hip pain. She has predominately been treated surgically via labral repairs and muscle reattachment. Her most recent symptom exacerbation involved putting on her socks about a month prior. She heard a pop as she bent over and could not walk.

She initially saw two ortho docs. One specializes in total hips, the other in scopes.  Since she was not appropriate for a total hip, this doc referred this lady to his associate.

After some imaging was done, she found out that she could not have surgery because she had several muscle tears. Or in the language that the doctor used:

“I have nothing to work with. Your hip is shredded up like cheese.”

This lady knew no other treatment but surgery, and hearing this news was devastating for her. Thoughts of a brutish life and an end to her fulfilling job flooded her mind. This doc referred to PT while conveying to the patient that this avenue was a mere dumping ground.

The Subjective

She walks back into the evaluation room, limping with the cane in excruciating pain.

Healthcare practitioners are the hardest people to treat. Knowledge is power, but the extensive biomechanical knowledge she had was detrimental in this case.

The subjective basically consisted of her telling me all the biomechanical issues she had. This pain is the bursa; running around the gluteus medius and minimus, down the illiotibial tract, blah blah blah puke.

But I listened intently to her story and how this recent episode devastated her life.

I finally asked her what her goal was for therapy? She replied…

“When you have a hip like this, what goal can you have?”

There were so many strikes against me for this lady. If you factor in what her history, what doctors said, her thoughts on her complaint, her belief that therapy could do nothing, her lack of goals, and her pain severity; let’s just say I was quite overwhelmed.

After I composed my thoughts, I knew what needed to be done.

Challenged accepted.


I performed an abbreviated objective exam to determine movement sensitivity and autonomic nervous system status via PRI testing. Based on my tests and measures, she was classified from a PRI perspective as a normal human being from the planet where?

Answer: Earth

I told her this finding, and proceeded to go into explaining how pain works. You never know how someone so indoctrinated into a biomechanical model is going to react to this thought process, but it was the only shot I had.

I used the analogy of pain as a sophisticated home security system. One so sophisticated that it can differentiate when calling 911 is appropriate; 911 being pain. Her hip trouble history was similar to being robbed in the past, so her home security system called 911.

If you have been robbed once, you will likely take extra precautions not to get robbed again.

Therefore, when she does something nonthreatening like put socks on and gets excruciating pain, it is not necessarily because she got robbed. It is as if her main console (i.e. her brain) calls 911 just because someone suspicious is walking near the street to her home. This episode was the result of her security center calling the cops at an inappropriate time.

Surprisingly, she totally understood this explanation, and gave me the following response:

“I never had anyone explain it to me that way.”

I sealed the deal by using her current hopelessness to my advantage. I mentioned that she felt this was the only option she had left. I felt I could help her as long as she put in the work.

She was sold.

The treatment we worked on was simply working on her breathing in hooklying. I helped her guide her ribs down to get as much exhalation as possible. We worked on this for about 10 minutes until she got the concept.

I reassessed all her hip motions…No pain. She got up and walked…No pain. She looked at me and asked:

“What the hell just happened?”

I told her we got her home security system reset via the autonomic nervous system.

She walks back into the evaluation room, limping with the cane in excruciating pain. She leaves the evaluation room smiling and holding the cane.


I don’t know what pisses me off more with this case, the words her doctor used, or the fact that this lady had never heard how pain works.

She was a healthcare practitioner who had no idea that pain worked in this way, and that scares me.

We see two very influential professions who think purely from a biomechanical model, and likely explain complaints to people in this fashion.  Think of the number of people these clinicians will see, perpetuating biomechanical faults as the sole cause of one’s pain. We can see now why our jobs are challenging.

Pain neurobiology is becoming more prominent in the PT realm, but we are only small fish in a very big pond.  And due to our status, we will have a hard road ahead converting medicine to this model.  I was lucky in this case, but I cannot tell you how many times I lose a patient when I go this route.

A few get it, some superficially get it, and many will not buy it.

Why is something so prominent in the research not standard operating procedure? Why is it that the evidence states giving biomechanical explanations leads to worse outcomes, yet this way is the norm? Why is it so hard to change?

But I see a paradigm shifting over the horizon. A light at the end of the tunnel. I got another healthcare provider to realize current pain theories, and she is eager to learn more. I feel we need to focus more of our efforts here.

We need to stop arguing with each other over which treatments do and do not work and the rationale why. We are all attacking the same thing under the same framework. We are all reducing the perception of pain as a threat.  And that is all pain is. A perception.

We need to shift our focus to educating those professionals not initiated on how this science works. We need doctors, nurses, therapists, front office staff, and everyone else involved in health care all on the same page.  And until we do so, we will be stagnant in our current state.

The arguments we make regarding treatment will not matter until we educate the masses on the underlying framework for their pain experience.

Educate on.


  1. Great job again Zac. This is frustrating for all of us following the Pain Science model. The worst part is I feel all alone in this because even people in my practice use biomechanical explanations, not to mention the patient going back and possibly speaking with any other number of family, other practitioners etc, and you are the only light in a very dark tunnel. Have fun at the course and sorry I missed it! Hopefully she’ll come back feeling just as good as when she left.

    1. Erson,

      That is where educating your fellow practitioners comes into play. I have been fortunate that my coworkers are open to my educational process, and I hope to record a talk that I give to my entire staff soon.

      Wish you were here as well. AI day 1 has been excellent.

  2. Such an inspiring read!! I’m now half way through “The Sensitive Nervous System” and I’m loving every single word of it. It is fascinating how great influence education and one’s mindset has over pain. As therapists we really possess a huge responsibility and should carefully choose the words we use.
    Keep it coming!

    1. Thank you for the kind words Morten. That is where the psych of biopsychosocial comes in, so you are spot on.

      Keep up the great work and enjoy TSNS; phenomenal read.

  3. Zac,
    Great post! Great discussion and what she heard is consistent with so much that medical professionals are feeding patients and taking away their locus of control.
    Looking forward to a review from this weekend : )