Someone walks in convinced the problem is their back. The ache sits low, it has been there for months, and every conversation so far has been about the spine. Then you ask where exactly it hurts, and the answer is the groin.
That moment is the whole subject of this week's Pain 2 Power. Dr. Dave Kashuba and Mike McGann sat down with orthopedic surgeon Dr. Zach McVicker of the Paley Orthopedic and Spine Institute in Jupiter, who spends his days on the joint that keeps getting blamed on its neighbor.
By The First Rehabilitation Team · Reviewed by Dr. Dave Kashuba, Ph.D.
Why a hip surgeon ended up on a back pain show
Dave set the table with a reminder from a few shows back, when what walked in as ordinary back pain turned out to be cauda equina syndrome, a problem that could have killed the man who had it. Most days the answer is far less dramatic. The lesson holds anyway. “If you have a good therapist, a good person looking at them, you realize that it's not back pain,” Dave said.
The pattern he listens for is pain that travels toward the groin rather than down the leg. That points at femoroacetabular impingement, which everyone in the field shortens to FAI, and when Dave suspects it, Dr. McVicker is the surgeon he sends people to. Dr. McVicker is as good as anybody on a shoulder or an elbow, Dave said, “But what he loves is hips.”
Who Dr. McVicker is
Dr. McVicker is board certified by the American Board of Orthopaedic Surgery and fellowship trained in sports medicine at the Cedars Sinai Kerlan Jobe Institute in Los Angeles. He has served as assistant team physician for the Miami Marlins and the Jupiter Hammerheads, and he practices with the Paley Institute in Jupiter and West Palm Beach, focusing on minimally invasive arthroscopic surgery of the hip, knee, shoulder and elbow.
He joined Paley in 2022, as he remembered it, to build its sports medicine program. The institute already did plenty of hip preservation work, but until he arrived nobody there was doing arthroscopic hip surgery.
What hooked him on the joint is the detective work. “Sometimes you got to think outside the box with it. And that's what I really like about it,” he said. He called the hip “more of a puzzle,” the kind where you have to find the root problem before anything else in the picture makes sense.
What a hip problem looks like when it's posing as something else
Mike asked the question listeners actually want answered: when should somebody pick up the phone? Dr. McVicker didn't hesitate. “I think that groin pain, number one, that's the most common symptom.” Then he ran through the ones that send people down the wrong hallway for months.
- Low back pain, often the complaint people walk in with
- SI joint type pain, which he described as pain toward the buttock
- Pain on the outside of the hip
- In some people, pelvic floor dysfunction, because some of the muscles involved with the pelvic floor get pulled into the hip problem
- Trouble walking at all, which he summed up as “It stops them in their tracks”
His rule for when to get the hips looked at was refreshingly plain. “If people can't find a reason for these things, you know happy to take a look and see if the hips are an issue, but often times they are.”
Dave added the activities that tend to light it up: anything that puts torque or weighted pivoting pressure through the joint, with golf near the top of his list. He also made a point about who is getting this diagnosis in our corner of Florida. “We have 70 year old sports minded people that are playing tennis that are having this syndrome for the first time,” he said. Drive past the courts along US-1 on a weekday morning and you'll see that crowd.
Mike's frozen hip
Mike had his own version. Around 2018 or 2019 (he and Dave spent a minute deciding whether that counted as pre-mask), X-rays for his long-running back trouble showed a hip that was frozen and had probably been stuck that way for years. Once it was worked loose, the change surprised him.
The hip had been causing trouble in his “lower back, upper back, all down that side,” he said. “And it was just something in the hip that caused all of that.” The point was how far one ball and socket joint can throw its problems.
Cam, pincer and dysplasia: three shapes behind most of it
Dave asked the question a therapist would ask. Does this look different in men and women, and does that change how you operate? It does. FAI comes in two shapes, and Dr. McVicker has a plain way of describing each. In a cam lesion the ball itself is misshapen: “instead of being round, it's more like an oval peg in a round hole.” In a pincer lesion the socket covers too much of the ball.
Later, when Mike asked what he sees most, a third shape came up. Hip dysplasia, the second most common problem in his practice, is the mirror image of a pincer. The socket is underdeveloped, so there simply isn't enough dome to spread your weight across.
| Problem | What is off about the shape | Who it tends to show up in | What he said about it |
|---|---|---|---|
| Cam lesion | The ball is misshapen, “more like an oval peg in a round hole” | More often men | A mismatch between the shapes and how the joint is supposed to move |
| Pincer lesion | The socket covers too much of the ball | More often women | Technically more challenging to treat; the labrum is often calcified and may need reconstruction |
| Hip dysplasia | The socket is underdeveloped, with too little dome | Gymnasts and dancers who trained for hours a day while still growing | Edge loading that “ends up in arthritis 100% of the time” |
The gasket
The labrum is the piece Dr. McVicker wanted people to understand. Think of a gasket between two pipes, he said. In the hip it creates negative pressure, a suction seal, so that every time you walk the contact pressure spreads across the whole dome of the joint. Lose the seal and that pressure concentrates on cartilage that was never built to carry it that way.
Mike did the math out loud. Think about what the top half of your body weighs, carried with every step. You're asking the joint “all of a sudden to carry so much more weight at specifically targeted areas,” he said. Once the labrum is involved, the conversation went, it hurts with every step and people end up dragging the leg.
Why the pincer side is the harder repair
By the time a pincer hip reaches surgery, the labrum is often calcified, and it may need to be reconstructed rather than simply repaired. He was frank that this is the more technically demanding operation and needs a very experienced surgeon. Dysplasia, meanwhile, has its own typical patient. “The typical one would be like a gymnast or a dancer, you know, who has been dedicating 5 hours a day for years and years and years while they're developing,” he said.
Arthroscopy early, or a replacement later
Arthroscopic hip surgery is small work. Little cameras, little poke holes, and a recovery Dr. McVicker described as much less painful than a total hip, though getting back to sport takes a little longer. From the therapy side, Dave sees those athletes back running quickly. “Once you're good, you're good,” he said.
The trade Dr. McVicker cares about is a different one. A replacement gets you feeling fairly normal fairly quickly, “but it's not your own hip. You don't have the proprioception” that a native joint gives you, along with the balance that comes with it. Dave framed it as catching the problem before you need one of the hip replacement surgeons he planned to bring on the show, and a couple of episodes later he did exactly that with Dr. Michael Leighton, MD.
The finger test
Dave picked up the word proprioception and turned it into something you can try at the kitchen table. Close your eyes and put your hand out to the side. Have someone lift one of your fingers, up or down. Can you tell which way it went without looking? People lose that sense, Dave said, and in the legs losing it means missteps.
Missteps become falls. Mike connected the rest of the chain: “once that hip break happens, there tends to be a really strong domino effect from there.” Dave added that women, with wider hips and more laxity in the joint, need to be especially careful not to brush off back pain or groin pain. If balance is on your mind, our piece on strength training after 60 and fall prevention picks up that thread.
Where physical therapy fits, and a ten minute conversation
Behind most painful hips Dave finds a weak gluteus medius, the muscle that keeps your pelvis level when you stand on one leg. His home program starts with sit to stands done with a resistance band looped just above the knees, so a sore hip can't shift your weight onto the good side, then adds abductions, clams and a prone press up. Every one is written out on our home exercise page, and the reasoning behind the order is in our longer piece on hip impingement and back pain. He added a practical note: before you get down on the floor, make sure you can get back up.
The day to day changes matter as much as the exercises. Dave's list was short: avoid sitting with your legs crossed, cut down on repetitive bending, and modify the tasks that set it off. For golfers that can mean changing the swing rather than giving up the game. “There's ways to change your golf swing and modify your swing,” he said.
Sorting out which doctor you need
Dave also described what happens when somebody isn't sure where to start. “It takes me all of 10 minutes for me to sit down with you and go over a little bit about your symptoms,” he said, and from that conversation he knows whether to send you to Dr. McVicker, to a back doctor, or to an orthopedic surgeon who specializes in something else. Free consultations are available at the clinic. You call to schedule one.
If you do need therapy, Florida's direct access law lets most people start a physical therapy evaluation without a referral, though some plans still want one and Medicare needs a physician to certify the plan of care. The front desk checks all of that before your first visit.
The part of the episode that wasn't about anatomy
Dave told a story on his guest. Sometimes at 8:30 at night he'll text about a patient, expecting nothing until morning, and the phone dings back with Dr. McVicker agreeing, disagreeing, or suggesting a next step. To Dave, that's a surgeon who cares how his patients come out.
Dr. McVicker put it in his own terms. This kind of problem is “very, very complicated. It's very intertwined,” he said, so you “have to listen to people a little bit longer, and you have to care.”
Mike put him on the spot for a favorite case. He told one that keeps repeating: a high school athlete with college plans, told nobody can treat this and the career is over. “We've had that several times, and they go on to play college sports and they keep going on,” he said. Then the part he clearly enjoys most. “Getting that hug at the end when they're rehabbed and they feel great, there's nothing better than that.”
Dave closed the topic his usual way. Whoever you choose, “do your research before you go. Don't listen to the lady at the water cooler or in the Publix line.” Then he asked Mike what one snowman said to the other. (“Hey, do you smell carrots?” Mike promised to use it somewhere, with credit.)
Hear the whole conversation
One bit of trivia from the top of the show. Mike asked whether our phone number was planned. Not exactly. It belonged to a hand therapist friend of Dave's, and when she retired he asked for it because surgeons remembered 624-HAND. Later he noticed the same digits spell 561-624-GAME, which let him get “hips and shoulders and everything else, not just hands.”
Listen to the full episode on the Pain 2 Power podcast page or watch it in our video library, and if you're curious about the peptide conversation Dave teased at the end, the next week's guest was Paul Joyce, recapped in our Episode 11 write up. You can also read how we approach hip pain and back pain, or see how our physical therapy program is built.
If your back pain has never quite added up, or the ache shows up in your groin when you stand from a chair, come let us take a look. The clinic is at 733 US Highway 1, Suite 2A in North Palm Beach, with a free lot right at the building. Call us at 561-624-4263 or request an evaluation.
This article is general information, not medical advice. Every situation is different, so please consult a qualified professional about yours.