About the Author:Eric Bowman is a Registered Physiotherapist in Ontario, Canada who works in the areas of orthopedic physical therapy and exercise for people with chronic diseases. He’s also intermittently involved with the University of Waterloo Kinesiology program and the Western University Physical Therapy program. He also competes as a powerlifter in the Canadian Powerlifting Union and has completed the CPU Coaching Workshop & Seminar.
This past weekend (as of the time I’m writing this on a train to Toronto), Coach Travis Mash and I had a discussion regarding options for hip osteoarthritis (OA) and whether hip resurfacing, hip replacements, or stem cells would be the best option. It’s an understandable question given that OA is one of the two big musculoskeletal pain problems in today’s society (along with low back pain) and, given the aging of the baby boomers, it’s expected that these will rise.
Serious athletes aren’t immune from this either. A recent paper showed that competitive runners were actually at a higher risk of developing OA than sedentary individuals. Heavy athletes (such as powerlifters, strongman, football players and bodybuilders) are at a higher risk of OA even when generally healthy.
It’s impossible for me to make recommendations for each individual with hip pain and hip OA without assessing them and understanding their situation. That said – people need to know the risks and benefits of the different, more invasive, options for hip OA.
First Things First: Conservative Options
I’d be crazy if I didn’t first recommend the simple steps for helping with hip OA which can greatly improve symptoms and have considerably lower risk compared to the options which I will discuss later on the article. The more conservative options include:
Losing weight: Increased body weight is a big risk factor for OA, and some research has shown that losing weight is associated with improved pain and symptoms. If you’re considerably overweight and unhealthy, working with a doctor and a certified exercise physiologist (through ACSM or CSEP) is a good start to improving your symptoms.
General strengthening of the hip, thigh, and core muscles: Powerlifters and weightlifters are pretty good with strengthening the quads, hamstrings, and glute max muscles as they are the ones that contribute to success in the squat, deadlift, snatch, and clean and jerk. But in many weight training clientele I’ve worked with, the abductors (i.e. glutes medius & minimus), adductors, and hip rotator muscles tend to be neglected. Strength athletes (with the exception of strongman) tend to train only in one plane of motion. If you aren’t training all of your hip and your core muscles, that’s another vital step that may improve your symptoms. Worse comes to worse – you’re better off coming out of the surgery.
Improving sleep: Poor sleep can be a risk factor for a lot of different musculoskeletal pain conditions and for chronic pain. Some simple steps you can to improve your sleep are:
Going to bed and getting up at the same time every night
Limiting (if not eliminating) caffeine and alcohol use after lunchtime
Minimizing screentime before bed (I’m a bit of a hypocrite and struggle with this part)
Making sure the environment is cool, dark, and quiet
If you find these steps aren’t helping your quality of sleep, I recommend you get a sleep study – especially given the amount of bigger athletes who have sleep apnea and rely on CPAP machines.
Managing psychosocial factors like stress, anxiety, and depression: these are major risk factors for chronic pain and poor recovery. I’m not a doctor (nor did I stay at a Holiday Inn Express last night) – but if simple steps such as eating right, exercising regularly, sleeping well, and better time management/organization aren’t helping … then it’s worth seeking out professional counseling or help to deal with these issues.
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Now with that out of the way, it’s time to answer Travis’s question: hip replacement vs hip resurfacing vs stem cell therapy – which is the best option?
Stem Cell Therapy
I could only find two human studies on PubMed which totaled 28 participants who were undergoing stem cell therapy for OA of the hip. These studies showed a slight improvement in pain with no complications.
As a disclaimer these studies were done in very small populations and research is needed to determine how long these effects last. My personal (anecdotal) bias and observations of any kind of cell injection are that many of them have shorter lasting effects in people.
Hip Resurfacing vs Hip Replacement
This area has been much more thoroughly researched and is an area I have considerably more experience with through doing a placement/internship at University Hospital in London, Canada. There I saw numerous clients post hip replacement (total hip arthroplasty) and resurfacing from surgery to discharge. I’ve seen the surgery done in person and have gotten to meet some of the surgeons involved in the practice guidelines surrounding THAs.
In terms of short term outcomes, some research has shown advantages of hip resurfacing over hip replacements, such as:
Less pain 24 hours post-surgery
Shorter hospital stay (by about 2 days on average)
Less blood loss and transfusions
Lower rate of hip dislocations
In terms of overall pain and functional outcomes, aside from a few odd questionnaires here
and there, the outcomes for pain and physical function are generally the same between the two
The big advantage of hip replacement over hip resurfacing is that the implements last longer and need less revision.
In my experience, and the research says this, the vast majority of people do quite well after a hip replacement … and the anterior hip replacement approach has good evidence when compared to the lateral and approaches. The people whom I see struggle are:
People who have let themselves go and are incredibly obese, weak, and/or inflexible heading into surgery.
Those who don’t do their exercises and/or are afraid of moving the operated hip for fear of pain or damage.
People who unfortunately suffer from central sensitization, a condition in which the entire nervous system and body is hypersensitive and produces excess levels of pain in response to stimuli. These are examples of people where a more generalized approach focusing not just on exercise or surgery but on general health (i.e. diet, sleep, stress, beliefs) can be necessary and essential.
Again – it’s impossible for me to make specific recommendations without knowing your situation, but I hope this provides some useful tips for future consideration. As always, thanks for reading.
Ortiz-Declet VR, Iacobelli DA, Yuen LC, Perets I, Chen AW, Domb BG. Birmingham Hip Resurfacing vs Total Hip Arthroplasty: A Matched-Pair Comparison of Clinical Outcomes. J Arthroplasty. 2017 Dec;32(12):3647-3651. doi: 10.1016/j.arth.2017.06.030. Epub 2017 Jun 23. PubMed PMID: 28711342.
Shimmin AJ, Baré JV. Comparison of functional results of hip resurfacing and total hip replacement: a review of the literature.Orthop Clin North Am. 2011 Apr;42(2):143-51, vii. doi: 10.1016/j.ocl.2010.12.007. Review. PubMed PMID: 21435490.
Alberta Hip Improvement Project., MacKenzie JR, O’Connor GJ, Marshall DA, Faris PD, Dort LC, Khong H, Parker RD, Werle JR, Beaupre LA, Frank CB. Functional outcomes for 2 years comparing hip resurfacing and total hip arthroplasty. J Arthroplasty. 2012 May;27(5):750-7.e2. doi: 10.1016/j.arth.2011.10.004. Epub 2012 Jan 28. PubMed PMID: 22285258.
Yoon RS, Geller JA, Nyce JD, Morrison TA, Macaulay W. Hip resurfacing is less painful at 24 hours than hip replacement.Orthop Clin North Am. 2012 Nov;43(5):e8-13. doi: 10.1016/j.ocl.2012.07.002. Epub 2012 Sep 8. PubMed PMID: 23102425.
Marshall DA, Pykerman K, Werle J, Lorenzetti D, Wasylak T, Noseworthy T, Dick DA, O’Connor G, Sundaram A, Heintzbergen S, Frank C. Hip resurfacing versus total hip arthroplasty: a systematic review comparing standardized outcomes. Clin Orthop Relat Res. 2014 Jul;472(7):2217-30. doi: 10.1007/s11999-014-3556-3. Epub 2014 Apr 4. Review. PubMed PMID: 24700446; PubMed Central PMCID: PMC4048407.
Emadedin M, Ghorbani Liastani M, Fazeli R, Mohseni F, Moghadasali R, Mardpour S, Hosseini SE, Niknejadi M, Moeininia F, Aghahossein Fanni A, Baghban Eslaminejhad R, Vosough Dizaji A, Labibzadeh N, Mirazimi Bafghi A, Baharvand H, Aghdami N. Long-Term Follow-up of Intra-articular Injection of Autologous Mesenchymal Stem Cells in Patients with Knee, Ankle, or Hip Osteoarthritis. Arch Iran Med. 2015 Jun;18(6):336-44. doi: 015186/AIM.003. PubMed PMID: 26058927.
Mardones R, Jofré CM, Tobar L, Minguell JJ. Mesenchymal stem cell therapy in the treatment of hip osteoarthritis. J Hip Preserv Surg. 2017 Mar 19;4(2):159-163. doi: 10.1093/jhps/hnx011. eCollection 2017 Jul. PubMed PMID: 28630737; PubMed Central PMCID: PMC5467400.
Issa K, Palich A, Tatevossian T, Kapadia BH, Naziri Q, Mont MA. The outcomes of hip resurfacing compared to standard primary total hip arthroplasty in Men. BMC Musculoskelet Disord. 2013 May 8;14:161. doi: 10.1186/1471-2474-14-161. PubMed PMID: 23656900; PubMed Central PMCID: PMC3652766.
Ward WG, Carter CJ, Barone M, Jinnah R. Primary total hip replacement versus hip resurfacing – hospital considerations.Bull NYU Hosp Jt Dis. 2011;69 Suppl 1:S95-7. PubMed PMID: 22035493.
Penny JØ, Ovesen O, Varmarken JE, Overgaard S. Similar range of motion and function after resurfacing large-head or standard total hip arthroplasty. Acta Orthop. 2013 Jun;84(3):246-53. doi: 10.3109/17453674.2013.788435. Epub 2013 Mar 26. PubMed PMID: 23530872; PubMed Central PMCID: PMC3715815.
Some love it. Some hate it. But what’s the truth on the Bulgarian Method?
The Bulgarian Method (made famous by the late Coach Ivan Abadjiev) was a system comprised mainly of the snatch, clean and jerk, front squat, power snatch, and power clean. The athletes in this system would work up to a max for the session with a few back-off repetitions, and this would take place two to three times per day and seven days per week.
Yes, this is an extreme system. It worked in a country riddled with drugs and a national system with a funnel of athletes. I don’t believe it to be the most optimal system due to the obvious risk of injury and overtraining. However, I don’t ever recommend throwing out the baby with the bath water.
A.S. Prilepin worked within the Soviet weightlifting program from 1975-1985, allowing him to extract data from thousands of top athletes. To me that makes his studies more applicable than any kind of study performed at a university with a few college students. Prilepin determined that intensities over 90% were the best loads for getting stronger. Without a doubt, if you want to get stronger, you are going to need to go heavy.
I have developed twenty athletes for Team USA since 2015. Every athlete on my team goes through a Bulgarianish block of training. However, how often and for how long depends on the individual.
When I say Bulgarianish, I am simply referring to a high intensity and high frequency block of training. No one I know truly trains year-round two to three times per day to a maximum. But if you want to get an increase in a particular lift of two, there is nothing better than high intensity and high frequency.
My programming has evolved multiple times over the past four years. We tested out high intensity and high frequency as a base program, and it worked for some. We’ve tested out programs that averaged right around that 80% intensity range, and that style worked for some. However, a mixture has proven to yield the best results in our experience.
Our programming looks something like this:
Accumulation: get the body acclimated with movements that are out of the ordinary, giving the joints and the mind a bit of a break. This block is hypertrophic in nature.
Hypertrophy: this block is similar to the accumulation phase, but the movements become a bit more specific.
One to two strength blocks with average intensities of around 80%: the focus is efficiency in sport specific movement. The volume will be higher during this type of a block to produce a neural efficiency response. The secondary focus is strengthening weaknesses and strengthening the muscles directly related to the sport specific movement.
One to two High Intensity and High Volume Blocks with average intensities around 90%: The overall volume during this phase is a bit lower to allow for as much recovery as possible. Now we are preparing the body both muscularly and neutrally to withstand higher loads. This phase is the most specific.
Peaking/Taper Block: this is normally four to six weeks depending on the person. The focus is on specificity of the competition movements, while maintaining the special strengths developed in the previous blocks.
Each of these blocks is specific to the individual. All of my athletes will at least perform each of these blocks for some amount of time. Within each block, there are several variables that must be considered to produce the optimal program for the individual. Here are just a few variables that must be considered:
Average weekly and daily volume
Average weekly and daily intensity
Weakness and asymmetry driven accessory work
Duration of the phase (two to eight weeks)
Frequency of the individual movements
A lot of these variables are determined by the characteristics of the individual athlete. Here are a few of the characteristics that we look at:
Level of performance
For a more detailed explanation of all of these variables and how we customize programs to the individual, check out our guide Mash Files.
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We don’t even come close to performing a Bulgarian block, but almost all of my athletes perform a high intensity and high frequency block.
Here’s a sample of what a week of “HIHF” might look like:
Snatch (from blocks with bar at knee): 1RM
Clean and Jerk: 75% x 2, 80% x 2, 85% x 1, 78% x 2, 83% x 1, 88% x 1, then work up allowed 1 miss
Front Squat : 1RM (paused 3 sec)
Clean Pulls: 4 x 3 (work up heavy, starting at 90%)
Power Snatch: 65% for 2 x 3, then 3RM
Behind the Neck Jerk (from racks/blocks): 75% x 3, 80% x 3, 85% x 2, 75% x 3, 80% x 3, 85% x 2, then 3RM
Front Squat (with belt): 75% x 4, 80% for 2 x 3, 85% for 2 x 2, then find a 2RM
Reverse Hypers: 3 x 45 sec
Snatch: 75% x 2, 80% x 2, 85% x 1, 78% x 2, 83% x 1, 88% x 1, then work up (allowed 1 miss)
Clean (from blocks with bar at knee): 1RM
Upper Muscluar Imbalance Superset:
1a. DB Tricep Extensions: 3 x 10 reps
1b. DB or KB Push Presses: 3 x 10 reps
1c. Plate Front Raises: 3 x 12 reps
OH Squat: 3RM
Power Clean: 65% for 2 x 3, then 3RM (9RPE)
High Bar Back Box Squat + Bands or Chains: 40% bar weight + 30% bands or chains for 6 x 3 (60-90 sec between sets, velocity goal of 0.8 m/s)
Sled Bear Crawls: 4 x 30 yd
Clean and Jerk: Max
Front Squat (with 100 lb of chain): 1RM
Snatch Pulls (from blocks): 4 x 3 (work up heavy, starting at 90%)
Back Squat: 5RM, then -10% for 2 x 5
Clean Grip Deadlift : 3RM (first rep paused 3 sec at knee), then -10% for 2 x 3 (not paused)
Leg Curls (DB, Band, or TRX): 3 x 10
Unilateral Farmer’s Walk: 3 x 30 yd each hand
In this sample week, we are snatching four times plus an overhead squat. I mention the overhead squat in relation to the snatch simply because it’s specific to the snatch. We are performing a clean four times and jerking three times with one of those times being separate of the clean. I think it is important to split the clean and the jerk up at least once per week for a block or two to ensure that each movement is perfected separately.
We are squatting five times, but we are using a few variations to avoid accommodation. Chains and using a box are both ways of minimizing recovery time. Chains deload when the range of motion is at the most extreme angles preventing some of the muscle damage. The athlete will still experience maximal weights up top, and they will improve in the area of compensatory acceleration, as they learn to recruit more and more fibers while standing up and overcoming more and more chain resistance.
We use pauses to limit the load and to encourage proper receiving positions in the clean. Pauses are also a way of stabilizing in the bottom position, which enables the athlete to absorb force more quickly during a clean. This allows them to catch the weight and change directions more quickly. We also use velocity as a tool to focus on maximal speed with moderate weights, which is what the sport of weightlifting is all about anyways. This is a time to focus on strength-speed, taking a break from the accelerative and absolute qualities of strength.
As you can see, we use much more variety than a typical Bulgarian Program. We also use a bit more volume because our athletes need more practice with the movement. When my athletes such as 15-year-old Morgan McCullough and 16-year-old Ryan Grimsland have been competing for more than seven years at a high level, I might consider a “HIHF” block with less volume because they will have hopefully perfected the movement at that point. Most of the Bulgarians started their training much younger than most Americans. General physical preparedness was handled in the school system, and from there the athletes were placed in the sport that fit their genetics. In America we get athletes, such as Hunter Elam, who is amazingly strong and athletic but didn’t start weightlifting until she was in her twenties. She still needs more practice at the lifts to perfect the movement.
I will always use accessory movements to strengthen the weaknesses of my athletes. Do I believe that accessory work will lead to a bigger snatch? In some cases it does. Accessory work definitely helped to improve Hunter Elam (who had a pretty big overhead deficiency). But accessory work doesn’t always help to improve the snatch and clean and jerk in all athletes. I still use accessory work a lot, however, because accessory work prepares the body to handle the beating placed upon it by the sport of weightlifting. Accessory work also helps to correct asymmetries, which can cause injuries over time.
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I will conclude with this quote from a man much smarter than me:
“Muscles and the CNS can only adapt to the demands placed upon it. Thus the… maximal effort method is considered superior for improving intramuscular and inter muscular coordination”
Science and Practice of Strength Training – Zatsiorsky
Yes, going heavy is the quickest way to getting stronger. However, a lot of athletes who have come and gone in America have proven it’s very hard to withstand day-in and day-out and year-after-year.
But that doesn’t mean to throw out the baby with the bath water. You definitely want to add in block of high frequency and high intensity, depending on the individual needs of each athlete. I recommend using this method with a bit more of a balanced approach in regards to accessory work, strength work, and volume.
When I was talking recently with my friend Dr. Andy Galpin, he mentioned he was a big fan of Cal Dietz’s Triphasic Training.
And if you’ve been in the strength game for any amount of time, you’ve surely heard of it.
I was so excited to have Cal on the podcast today to talk with us. He’s doing a lot of crazy things in the gym that sparked my curiosity – stuff like having his athletes squat with their heels up. Or Cal’s love of the single leg squat with a safety squat bar.
Cal talks about such profound training concepts, but he has an ability to break it down and make it sound so simple.
The concepts Cal talks about with us could allow any athlete to make big changes or just slight changes to their training – whether the athlete is into weightlifting, powerlifting, CrossFit, or field sports.
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“Balance is not something you find, it’s something you create.”
– Jana Kingsford
For most of us, we have obligations outside of the gym. Some of us work out simply for our health, while others of us are training at a high level for our sport (i.e. weightlifting, powerlifting, CrossFit). There is only a very small percentage of athletes who have the ability to treat training and recovery as their full time job without distractions. Obligations can be work related, school related, or family related. We can make a million excuses about not having time to go to the gym (and many of these excuses may even be valid). The bottom line is that we make time for things that are important to us. No matter how busy we are, if we prioritize our health and fitness as important, we will find a way. Balance is key!
Whatever combination of busyness you have, goal setting, prior planning, and time management are key components of successfully staying active in the gym and training. I am a wife, mother, coach, business partner, and elite athlete. Each of my days are spent doing a combination of these things:
Spending time with Wayne and Morgan – My husband and I find time throughout the busy day to go on walks or go to breakfast so we can have couples time. Morgan and I spend time together watching silly TV shows and talking on the way to and from the gym. THIS is my number one priority, but I know that I can always do a better job.
Coaching – I coach our morning adult fitness classes at L.E.A.N. two to three times per week as well as coach weightlifting with Travis each afternoon. I also travel to the National meets with the team to help Travis coach.
Managing a gym – I am the general manager of L.E.A.N., and I have daily obligations of answering emails, marketing, membership recruitment and retention, programming, cleaning, etc.
Training – I compete in powerlifting and train five to six times per week.
Programming for online athletes – I have 30 online athletes who I program for through our Silver Level program. I have weightlifters, powerlifters, and CrossFit athletes.
Customer service – I am the person you email when you need anything at the firstname.lastname@example.org email.
Podcasting – We spend three to four hours every couple of weeks talking to guests on the podcast.
Homeschooling Morgan – We are on a break right now (thank goodness!), but when we are in session, I grade his daily work and issue his tests to him.
This may look like a lot – and if I’m being honest, it is. However, I wouldn’t give up a single one of them! I have an amazing support system with my husband, Wayne, and my son, Morgan. Wayne has taken on two to three mornings of coaching adult fitness classes at the gym for me, and he coaches when I go out of town with our weightlifters. He will also start helping me with marketing and membership recruitment. He brings Morgan to the gym to train on the days I can’t come home mid-day. He cooks dinner, does housework, and helps Morgan with school. I couldn’t do all of this without him. Morgan keeps me accountable with my training and pushes me to always be the best version of myself. Both my husband and my son help me to stay balanced.
I say all of this, not for you to feel sorry for me or to brag, but to prove to you that with the goal setting, prior planning, and time management, it is possible to stay on track with your health and fitness despite all of your obligations.
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Women in the roles of wife and/or mom sometimes feel even more overwhelmed than men. We feel like there are certain things we are supposed to be doing. Giving up our own time for fitness is the first thing to go. We put others’ needs before our own. We identify as someone’s wife or someone’s mom, and we can lose ourselves if we don’t learn to find balance and prioritize.
I have found through trial and error that I have to go through a set of simple steps regularly in order to be successful. There are some weeks I am more successful than others. These are a few steps that I try to work on each week:
Set aside time to go to the gym and train. Make an appointment with yourself!
Set training goals. This can be as simple as getting in the gym x days a week or as specific as a meet or competition to train for. I personally find that I do better when I have a meet I am training for. When you have goals, you are more likely to keep the appointment you made with yourself. Be realistic with your goals.
Make a list and prioritize all the tasks you have to complete throughout your day. Check off tasks as you accomplish them. Block out specific time blocks for each task.
Lose the excess baggage. If there is something or someone bringing you down and keeping you from reaching your full potential, lose it. This can be as simple as getting off social media if it interferes with your productivity.
Have open communication regularly with your family and friends to let them know what you need from them as a support system to be successful.
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Here are a few additional pointers for moms and wives especially out there having a hard time balancing everything and on the verge of losing themselves:
Work toward an integrated life. Perspective is crucial in order to create harmony in your life – by having a balance of time for yourself and time for your family. If you have these two things, there won’t be guilt over all the other things. Only you will know the formula that works best for you.
Don’t feel guilty for finding a better version of yourself. What I mean is don’t stay home from the gym or fail to pursue dreams because you feel guilty for taking time for yourself. As my husband says (via a Rich Froning quote), “A happy wife is a happy life.”
Realize that following your dreams only encourages your children to follow theirs. You teach your children a valuable lesson of how important health and fitness is in their lives by including them.
Life will knock down even the best of us at times. Learn how to get back up, brush it off, and continue forward!
Creating balance in your life isn’t going to happen overnight. There are times you will feel overwhelmed. I still have my moments of being overwhelmed. Don’t let yourself get to this point if you can help it. Regularly go back to the steps and make sure your goals are realistic, the way you manage your time is working, and you have communicated your needs with your support system.
I hope this article gave you something to think about and can provide you with some simple strategies to maybe make your life a little less hectic without giving anything up you love!
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