Goodnight Nobody

6 Days Out From Shoulder Surgery

2012-01-15T06:49:00.002-05:00

I have been terrible about blogging once again so please accept my apologies. My shoulder surgery was 6 days ago, it was supposed to be just a distal clavicle resection. When my OS got inside he found a type 3 acromion so also performed an acromioplasty and a subacromial decompression.
The first 4 days were incredibly difficult and painful. On day 5 things got a lot better, the pain has gone down, I was able to stop taking narcotics, and I can almost dress myself all by myself.
My hip has been amazing since I've been on painkillers again. The last time I had hip pain was in the PACU immediately after surgery. I actually asked for ice for my hip, not my shoulder initially.
I had a lot of issues in the PACU this time and did not get along with the nurse who was assigned to me. This was my only bad experience ever at the hospital. Unfortunately it was my 6th surgery, I have pretty much figured out what helps my pain and what doesn't, as well as what I can tolerate. She was extremely stingy with pain meds and at one point she gave me 2 Percocet which didn't do a whole lot for me. After 20 min I called her over and asked her to give me something else. She said she could give me ocycodone, I said no, I want Dilaudid. She told me the order the anesthesiologist had put in was expired, so I told her to go call him and get another order. In the end it took her 45 min to get my meds. In the meantime I was lying in bed crying from the pain. She did nothing to help me or show she cared. In fact, the only person who showed any concern was my hip OS' PA who moved the ice from my shoulder to my hip. I finally got dialaudid and my pain got better.
I spoke with my hip OS a lite bit as well. I told him I still have butt pain and I'm seeing him next week so he has time to figure out why!
Once things calmed down with the nurse, I said to her I have has 6 surgeries here, I know what works for me and what doesn't. Of course she had a reply to that and told me that she also knows what works and what doesn't. Later in the day I asked her when I was due for more pain meds, she said 9pm but I should wait until I got home to take more. Luckily her shift ended and I was assigned a new nurse. He was amazing and I had him last time as well. At 8:55 I was ready to leave finally and asked him for pain meds. Without missing a beat he said of course, it would be so helpful for the ride home.

I'm really not sure how my hip is since the pain is been having has been masked by the meds I'm

taking for my shoulder. I has my first outing last night without a crutch so thrilled. It's been 61/2 weeks on crutches.

Shoulder Surgery Tomorrow

2012-01-08T19:43:00.002-05:00

The day I posted about my shoulder hurting I never thought would bring on a post with this title. But lo and behold here we are. Yes, I am still using one crutch and still struggling with my hip. I really hope I am making the wisest decision. I know that in about 3 months from now I will be very happy, it's hard to see that moment right now! I will update when I can!

Happy New Year Aetna Members

2012-01-01T00:32:00.001-05:00

This was recently posted as a comment under an older post.

Looks like Aetna has finally reconsidered their policy! Aetna posted this Clinical Policy Bulletin on 12/30/11 regarding
"Femoro-Acetabular Surgery for Hip Impingement Syndrome".

http://www.aetna.com/cpb/medical/data/700_799/0736.html

"Aetna considers femoro-acetabular surgery, open or arthroscopic, for the treatment of hip impingement syndrome medically necessary for persons who fulfil all the following criteria:

* Diagnosis of definite femoro-acetabular impingement defined by appropriate investigations, X-rays, MRI and CT scans.
* Severe symptoms typical of FAI and compromised function, with duration of at least six months where diagnosis of FAI has been made as above.
* Failure to respond to all available conservative treatment options including activity modification, pharmacological intervention and physiotherapy.
* Aged between 18 and 50 years (clinical experience has shown that these patients are likely to gain the greatest benefit).
* Absence of advanced osteoarthritis change on preoperative Xray (Tonnis grade 2 or more) or severe cartilage injury (Outerbridge grade III or IV).
* Absence of joint space narrowing on plain radiograph of the pelvis that is less than 2 mm wide anywhere along the sourcil.
* Member does not have generalised joint laxity especially in diseases connected with hypermobility of the joints, such as Marfan syndrome and Ehlers-Danlos syndrome.
* Member does not have osteogenesis imperfecta.

Surgery for FAI impingement is considered experimental and investigational for all other indications."

26 days post-op

2011-12-27T16:34:00.000-05:00

I feel the need to apologize to my readers who have come to expect detailed accounts of my recoveries and experiences. I guess with 3 kids aged 7,6 and almost 3, I just don't have the time. Keep in mind that at my first surgery I had 2 kids aged 1 and 2, yes, they are busy ages as well but there was no homework, after school classes, projects etc.
At 26 days things are going a lot slower than I had hoped. I am still on 2 crutches, desperately trying to get down to 1. I am using my brace when outside the house and trying to wean off of meds. I am still on Lyrica 2x/day for nerve pain. It is a lot better and I am trying to go to 1. I had to stop Mobic because I went into a horrible Crohns flare up. I occasionally take 1/2 Percocet at night to hep me sleep. I have a lot of pain in 2 out of 3 of my incisions, I'm not really sure why. They look good, have closed up but have a hard, marble like piece of scar tissue under the surface. I have been to PT a few times but am in miami now for 10 days so won't be going until I get home.
PT until now has included quad sets, glut sets, bridges, prone quad/abs/glute sets, hand heel rocks, bike, gentle shoulder theraband exercises with 25/75 weight bearing. At my last session we added stool rotations but at my own discretion I have stopped them. ROM is not my goal at this point and I don't want to push it. I am concerned that I already have regained too much ER so I don't need more.
I am extremely annoyed bc I still have posterior hip pain and pain with sitting and quite frankly it is a pain in the ass. I haven't addressed it w my OS as I just want to give it more time and there isn't anything he can do abt it. If I stay in bed I feel pretty good but when I do any amount of activity I get pain, mostly in the area of the incisions and occasionally it will move medially to the groin. I am using Lidoderm patches in that area, idk if they help or not though.
I am flying home alone with the 3 kids so I need to be much better in 8 days! Keeping my fingers crossed!

Outing to Jks 6th Birthday Party

2011-12-16T08:06:00.001-05:00

Op Report #5

2011-12-14T11:26:00.001-05:00

Op report

Preliminary diagnosis:
1. Right hip instability with labral deficiency
2. Capsular tear
3. Ligamentum teres tear
4. Loose body

Post operative diagnosis:
1. Right hip instability with labral deficiency
2. Capsular tear
3. Ligamentum teres tear
4. Loose body

Name of operation:
1. Right hip arthroscopy
2. Labral repair:augmentation using semitendinosus
3. Synovectomy
4. Removal of loose bodies
5. Debridement of ligamentum teres tear
6. Capsular shift procedure

Indications:
The patient suffered from persistent right hip pain and instability secondary to ligamentum teres rupture, iliofemotal ligament and capsular tear, loose fragmentation and labral deficiency. She failed non operative measures. She had clinical, radiographic, and diagnostic studies consistent with this pathology. Given her persistent pain and lack of improvement with non operative measures, she was indicated for a right hip arthroscopy and associated procedures.

Procedure:
After the patient was correctly identifies in the holding area, she was brought to the operating room. Spinal epidural anesthesia was administered She was placed in a supine position on the traction table and approximately 10mm of distraction were achieved across the femeroacetabular joint. The right hip was then prepped and draped in a standard surgical fashion. The lateral portal was established under fluoroscopic guidance using the seldinger technique. Then, a mid anterior and a distal anterolateral accessory portal were established. The distal anterolateral accessory portal was established as a separate incision for removal of loose fragments and also for the placement of the labral augmentation.

Initial evaluation of the central compartment demonstrated the cartilage surfaces to be in good condition. There was scarring and deficiency of the labrum between 12:00and 3:00. There was capsular attenuation anteriorly. There was a ligamentum teres tear with chondral and osseous loose fragmentation and subtle ligamentum teres tear. At this point the ligamentum teres Debridement was performed with removal of loose fragments, the largest measured approximately 5mm and this required an anterolateral accessory portal for removal. The scar tissue and adhesions were then removed from the area of labral deficiency and the edges of the acetabular rim were clearly demarcated. A good bed of bleeding bone was prepared between 12:00 and 3:00.

A semitendinosus allograft tendon was prepared on the back table and was inserted into the defect using multiple 1.4mm PEEK anchors. A total of 7 anchors were used to secure the graft in position and then side to side suturing of the labrum was performed to the native labrum anterior-inferiorly and posterior -superiorly. The labrum was then contoured to a normal anterior-inferior and normal posterior-superior labrum.

At the completion of the labral augmentation and the labral repair, removal of loose bodies, synovectomy and removal of scar tissue, all debris was evacuated from the central compartment.

The scope was then placed in the peripheral compartment, after the release of the traction, using the mid anterior portal. A capsular shift procedure was performed removing the distal aspect of the iliofemoral ligament to the proximal fragment using four #2 Orthocord sutures. Once this was completed and no further pathology was identified, the instruments were removed from the hip joint and it was drained of fluid and the arthroscopy portals were closed with 3-0 nylon sutures. A Marcaine cocktail was placed in the joint. The wounds were cleaned, dried and sterile dressings were applied.

The patient was awakened from anesthesia and was brought to the PACU having tolerated the procedure without complications.

Post op Appointment x 5

2011-12-14T10:03:00.000-05:00

I saw my OS yesterday, he is extremely happy with the way I am looking. I actually think he was pleasantly surprised to see me looking so much better than last week. He showed me the pics from my surgery (op report to follow). He is also really happy that my joint and cartilage look so good, despite having been in there 4 times already. He created me a new labrum with a semitendinosis allograft. At this point the most important thing is to protect the graft. I have to avoid extreme flexion and external rotation. At this time he wants me on crutches another 2 weeks and wearing my brace another 2 weeks.

He is also on board with me taking care of my shoulder in a few weeks. He thinks it makes sense to just get it all taken care of at once. So I will have the shoulder surgery on January 9th.

Things are coming along slowly. But I think that slow And steady is the way to go with this surgery.

Having a Meltdown

2011-12-08T09:02:00.002-05:00

Today has really been a challenging day for me. I woke up with all my nerve pain all over again. I know it's only been a week since surgery, and I don't know what I really expected, and I know in the past I have always gone through a rough patch. On top of this I can't get my mind off of the upcoming shoulder surgery. I had a long talk abt it with another hip friend last night, what she said was extremely helpful. She said no one else is going to understand. No one else gets it. You have to ignore the stupid comments and get over it. It's good advice for any of us in these situations. And of course, the worst possible comment is "you must like having surgery"

I texted my PT early today bc I am freaking out about the nerve pain coming back. His suggestion was avoid ankle pumps, avoid prone knee bend and go back on Lyrica. I am really not a fan of Lyrica and was thrilled when my OS told me I could come off of it. I guess I have to suck it up and stick with it bc my pain was great while I was on it

PT day 1

2011-12-07T20:51:00.000-05:00

So today was my first day of PT. Let me backtrack a little and tell you how my week has gone. Since I got home from the hospital, I have been incredibly dizzy and lightheaded all the time. I spent the majority of my day in bed with ice and my CPM. I was having a lot of nerve pain and having a lot of trouble getting into a comfortable position. On Sunday my OS and I emailed a little abt what to do. He wanted me on some sort of blood thinner to prevent blood clots since I was so immobile. He also wanted me on Lyrica for the nerve pain.

My husband didn't like the way I looked on Sunday so he called my brother in law who is a doctor to come over. He said the Percocet was dropping my heart rate too much which is why I was so dizzy.

I got off of the Percocet by Tuesday but it seems Lyrica also makes me dizzy.

PT went ok. My ROM is good and my strength too. My OS came by to see how I was doing since it has not really been smooth sailing for me. I told him the nerve pain is a lot better and I asked if I could stop Lyrica. He said yes so I asked for Lidoderm patches for the small areas of nerve pain.

My PT put me on a short crank bike but I developed groin pain after a few minutes. I did quad sets and glute sets and then iced.

I also had the opportunity to visit another hip friend in the hospital who had an FO yesterday.

I am now having groin and butt pain. I guess I overdid it today. I ended up taking half of a Percocet and hopefully I will wake up pain free tomorrow.

My Little Helper

2011-12-06T08:28:00.000-05:00

Zk rehabbing for me!

What My Day Consists Of

2011-12-05T14:08:00.004-05:00

Apparently nerve pain is worse than surgical pain, and I have a lot of it. My OS prescribed Lyrica and Mobic in hopes that it will go away. In the meantime, I gave a lot of trouble getting into a comfortable position. CPM is now my best friend!

Surgery#5........ Done!

2011-12-04T07:18:00.002-05:00

My surgery went well. My OS found exactly what he expected, a torn ligamentum teres, small labrum and very stretched out capsule. He debrided the ligament, augmented my labrum with an allograft and re-tightened the capsule.
The surgery was long and with prolonged traction time. The total time in the OR was about 4 hours and total traction time was 2 hours. My OS never keeps ppl in traction longer thx 1 hour. He needed the extra time to place the allograft down perfectly. He didn't think it would cause major issues given the instability that I have, there wasn't very much resistance when i was in traction.

I had a lot of trouble in the PACU between pain control and being dizzy so I spent the night in the hospital.
The traction is causing my leg to feel tingly and heavy and hard to move/walk. This is my 5th scope and I have never really used the hip brace but I am finding it to be extremely helpful in supporting my leg. I am also getting my money's worth w the cpm, I stay in it all day, even if it's off. I find the position comfortable. My OS doesn't want me in that position all day bc he's nervous I'll develop a contracture. If the leg issues r not better by Monday he will put me on Lyrica.
I think I covered the basics.

From what I recall, the report from my OS was that the looked great despite everything that it has been through. He also wants me to be extremely careful and mentioned something crazy about being on crutches for 4 weeks. I see my PT on Wed for my first visit so we'll see what he thinks.

Surgery is still going on

2011-12-01T14:02:00.003-05:00

for all you interested folks, susie is still in surgery. she's going on almost 3 hours now. here's a little pic of her walking into the or.

speak to you all later

- the most supportive husband susie has ;)

Surgery #5...Tomorrow

2011-11-30T15:59:00.002-05:00

I am having minor panic attacks but I should be ok! took Valium this morning and will probably take another one tonight. I am also going to try to have an acupuncture session tonight to help calm my nerves! Will keep you posted.

Fighting for out of network reimbursement

2011-11-26T23:14:00.002-05:00

Its funny how time flies and how little free time I have. Over the past week I have finally been able to make some real progress on my appeal to UHC for the amount that I was reimbursed for my out of network expenes. this was for the hand surgeon in August and my hip second opinion in August as well. I'll give you a hint of how things went...I did not get 70% of what was billed by the doctor as UHC makes you think you will. Check out this link to see what really has been going on with UHC concerning out of network reimbursement.

http://www.ama-assn.org/resources/doc/psa/ama-uhc-lawsuit.pdf

PS- In summary, the resolution of the class action litigation provides for UHC to pay a total of $350 million to fund the settlement for health plan members and out-of-network providers related to out-of-network services from March 15, 1994 through November 18, 2009. The settlement will be entirely funded by UHC and no recovery of funds will be sought from any self-funded customer plans.

T-10 days

2011-11-21T23:13:00.002-05:00

I can't believe my surgery date is just around the corner, I feel like I scheduled this ages ago, but yet here we are. I am eerily calm these past few days, I think once the whole snafu with the blood work was worked out I felt better. There was another issue with the letter form my gsatro, my OS office said they think it should be within 30 days of surgery. It is 33 days before surgery. I am not getting another one, this is going to have to be good enough, I am putting my foot down. They told me its possible that my surgery will be cancelled if the anesthesiologist has an issue, I am willing to take that chance! So the countdown begins now!

Aetna's policy #0736 is UNFAIR and UNETHICAL

2011-11-21T06:49:00.002-05:00

As many of you can attest to firsthand, Aetna is still not covering FAI surgery and still calling it "experimental", despite hundreds of peer reviewed articles that say otherwise. Although I do not use Aetna, I feel for all of you who do, and are not able to have your surgery paid for. Below is a link to a petition started by fellow FAI sufferer Ryan. Please take a few moments to look over the information and sign the petition if you agree.

http://www.change.org/petitions/aetnas-policy-0736-is-unfair-and-unethical

Sodium

2011-11-14T07:11:00.002-05:00

Well, the good news is that I was indeed dehydrated, my new labs showed that my sodium levels are normal!!! So, the good news is that I don't have some crazy hormonal issue, the bad news is that I have no excuse to get out of this surgery!! 17 days to go!

The Stress is Killing Me

2011-11-09T21:19:00.002-05:00

I am so sorry that I have not been keeping you updated with what is going on with my hip, but since we are 3 weeks away from surgery #5, I figured I'd better catch you up.

A few weeks ago, my OS office told me they would need a letter from my gastroenterologist saying it is ok for me to undergo a "low risk" surgery, since I have Crohn's disease. Keep in mind that they have never asked for that before. Fine, I took care of it. My gastro also wanted to run blood tests. As an added side note, the week I went to see him I was really sick and completly abusing Mucinex and Robitussin! I emailed him for the results of my bloodwork and was rewarded with this message: "your sodium level is too high. You cannot have surgery with these levels. You are probably dehydrated, drink lots of water and we will do the test again".

You can imagine that that email did not help my stress levels in the slightest bit. I was also leaving on vacation the next day, so I had all the time in the world to worry but no time to get the test redone!

Today I finally went for the blood work, I did notice that the first time my blood came out sluggishly, probably due to dehydration. Today it flowed nicely! Keep your fingers crossed that it is ok this time!

Vacation is a wonderful time to relax, rest, and de-stress. I did all of those. unfortunately there is absolutely no carry-over. When you get home all the shit you left is still there for you to deal with.

Today was also my second pre-op appointment. I was hoping that this appointment would calm my nerves but it didn't.

The message I left with is that my OS is really confident about this surgery (apparently he hasn't always been this confident in the past!) and a lot of my questions will not be able to be answered fully until he actually goes in, sees the damage, and repairs it. His repair will also dictate a lot in terms of how the rehab will go.

So I was hoping for a lot of concrete answers, and a little bit of inner peace. I got none. I did get to try on the new hip brace he is using and decided to get one. He also wants me using the CPM machine for 2 weeks post-op.

I wake up in a mini panic attack every morning. Dec 1 can't get here fast enough!

Shoulder Update

2011-09-27T21:13:00.002-05:00

I was able to get an appointment today for my shoulder, luckily, as I don't think I could have gone on for one more day with that pain. My shoulder OS was not happy to re-inject me at all :-( He was worried about fat atrophy and warned me that if ti happened I would not be happy. I explained that I am having hip surgery on 12/1 and cannot address shoulder until after that. I also added that it is hard for me to work and function at the moment given the pain. He thinks I need to get it taken care of, possibly before hip. Given my current mental and emotional state regarding my hip, that is not even up for discussion. He asked me how often I use my hip to manipulate a patient!!! Good point, but I'm still not even considering that. I think I am probably going to schedule it about 5 weeks after hip surgery, I know it is crazy but I need to get everything taken care of once and for all.

I spoke to my PT since I was at the hospital and we discussed my upcoming hip surgery and I wanted his take on the shoulder. He agrees that it needs to be taken care of and thinks 5 weeks after is not at all unreasonable.

So...hip then shoulder.......HEELLLPPP!

Why Why Why

2011-09-25T09:05:00.003-05:00

Aside from my ridiculous, drawn out hip issues, I think I have mentioned that I also have a shoulder issue. I have had 2 cortisone injections, the each last about 6 months. I am at that 6 month mark right now and in excruciating pain. the last time I saw my shoulder doc he warned me that he won't keep injecting me forever, eventually I will have to "address" the issue. "Addressing" the issue obviously means surgery, which at this point is just plain funny to me, I mean, how many surgeries can one person have in such a short amount of time?

At the same time though, how much pain can I deal with in such a short amount of time? People have suggested that I have my shoulder and hip done at the same time which must be just about the dumbest thing anyone could say. But, I am seriously considering doing it 4 or 5 weeks later...the pain is that bad. I have an appointment with my shoulder doc in about a month but there is no way I can wait that long. I am going to call today and beg and plead for an appointment tomorrow, I need an injection just to work, sleep, take care of my kids etc. And I will be open to discussing (not scheduling) surgery...I can't keep living like this.

On a brighter note, I have had to pop Advil like candy just to function with this shoulder pain and my hip is reaping the benefits!!!

The Pre-op Appointment

2011-09-08T07:02:00.002-05:00

I field a lot of questions from fellow hip pain sufferers, whether it be about surgeons, surgeries, insurance questions etc. I am more than happy to help since I know first hand what it is like to be alone and afraid and not have the answers. The only question that often times annoys me is "what should I ask my surgeon"? I really can't answer that, you need to ask him the questions that YOU have about your hip. What may be important to me may not be important to you and vice versa. With that being said, I went to my appointment with a LONG list of questions for my OS.

I needed this to help calm me down and get all of my questions answered. I also needed this to make it more "real" for me! It went really well and he answered a lot of my questions before I even asked them! Its good that we can still joke around about things bc it makes difficult decisions a lot easier! When I told him that I need the post-op/ rehab to be perfect bc this is the 5th time we are having this conversation, he jokingly said "No, its the 4th time, don't exaggerate!!"

So below are the questions I had written down to ask him followed by his answer. I also scheduled another appt a few weeks before the surgery bc I'm sure I will have more questions. If u think I left something out plz let me know and I will bring it up next time.

1)What r we calling the procedure?
Labral reconstruction
2)How long will the procedure take?
Forgot to ask!
3)Will I be able to go home that day?
Yes
4)What will u be using for the allograft for the labrum and the capsule?
Labrum- sometimes uses a rectus femoris autograft but will use semitendinosus allograft
Capsule- achilles allograft with synthetic scaffold
5)How do u secure the allograft?
The same way as a labral repair- with anchors and sutures + scraping bone to make it bleed a little
6)What exactly is the scaffold that u want to use for the capsule?
He used a name but I forgot! It has been used for rotator cuffs for abt 10 years
7)I really think its impt for the capsule to scar down- brace? For how long?
Not the philippon brace bc its not too effective, not hip dislocation brace bc I will be miserable- he found a different brace at bauerfiend, looks like philippon brace but "better", also 1 boot @ night to prevent rotation
8)What will my WB status be and for how long? Do we need to protect the graft?
Same as labral repair, labrum is not load bearing and only stressed in extreme ROM, so 2 weeks of 20lbs wb and mostly to my comfort
9)How long until I can drive?
When I am off narcotics
10)My hamstring tendon has a chronic tear, r u going to address it?
Prob not, it tends to tear with hip pain bc you post tilt your pelvis and it becomes shortened and can tear and in severe cases rupture. He may put in PRP
11)Sub spine impingement- do I have it?
Prob don't have it but will double check- doesn't really matter bc the part he will be scraping down to attach the allograft is where he would shave down
12)What do I do abt PT? I only want P...does he only see professional athletes these days :-)
Yes- professional athletes and me!!! Absolutely, he wouldn't have me go to anyone but P
13)Shoulder- when to get cortisone injection? I already had 2, shoulder OS said only one more- so do I get it now? Or will my shoulder be worse on crutches, should I save it for then? Or can I convince shoulder OS to inject 4x?
It will prob hurt on crutches but don't worry, I can inject it for u a 4th time but don't tell him :-)
14)Pre-op Class, do I have to go?
Yeah, if u want to teach it!!
15)Pre-op online questionnaire do I fill it out?

Yes, its like a report card on me! Hopefully one day ur score can be high!!
16)Post op appts- I want to see my OS at suture removal- receptionist said I can only see nurse- I was pissed!
I can see OS

I Scheduled It...AAAHHHHHH

2011-08-31T18:23:00.003-05:00

I was at work today, minding my own business, and my cell phone rang. It was my OS' surgical scheduler. And in a peppy voice, she said "Hi, I'm calling to schedule your surgery", as nonchalantly as someone would call and ask what I would like to order for lunch. I was a little caught off guard, but managed to hold it together long enough to get this done!

So, surgery #5 is scheduled for....drum roll please....December 1, 2011

Let the countdown begin! (anyone have a Xanax)

The Plan...Finally

2011-08-28T07:05:00.007-05:00

So after 6 months of pain, x-rays, MRIs, injections, talk of alternative therapies and talk of crazy surgeries, I think I have found my happy medium. I spoke with my OS and this is what we decided.

First of all, he is not upset at all that I went to see OS2, he said he prob should have sent me himself.
The only reason he has suggested open surgery for me is bc he feels that after 3 failed scopes, we prob should try something different. But at the same time, the scopes were all done for different reasons. Other than having to send a young patient for a hip replacement, one of the things he really hates is unnecessary open surgery. He told me there is nothing he cannot do arthroscopically that can be done with an open surgery. I think this was one of my happier moments of the past 6 months!
He said usually, in a scope, he will use an autograft from the capsule and rectus femoris to augment the labrum. Since my capsule is already compromised he will do it with an allograft. Since my capsule has already been repaired once and failed again, he will use allograft tissue there as well, he will also use a scaffold to strengthen it (this is apparently done often in shoulder surgery).

We discussed the ligamentum teres and my wishes for a new one! He said that u don't need it unless ur capsule is compromised. My thought is if ur already scoping me, just do it. He said it is EXTREMELY experimental surgery, they still don't know a lot about the biomechanics of it, and he wouldn't know how tight to make it, and he thinks I will hate it. He said right now I am having trouble bc the ligamentum teres is torn and getting caught. Once he debrides it and fixes the capsule, I will be happy again.

I am concerned about the post-op period, since I tend to be lax with the brace and weight bearing. I asked him to put me into a very restrictive brace post-op. He said absolutely, he will have me fitted for a hip dislocation brace and have it set to slight IR, and not allow more than 30' ER for the first 6 weeks. He warned me that I will hate it!! I'd rather be miserable for 6 weeks than be back to where I am right now in another 2 years.

I asked if he's ever scoped someone's hip 4 times, he said never his own patients, other ppls screw ups yes, but never his!

So I have to let him know when I want to do this, so he can plan accordingly, get his allografts and scaffolds together!
Even though it will be my 5th surgery, I am so happy that we have found a way to do it that doesn't make me want to throw up every time I think about it!

The Second Opinion

2011-08-25T05:23:00.002-05:00

Surprisingly, I got a call back from the second opinion doctor's office on Monday, and they were able to see me on Wednesday due to a cancellation. I was so happy but a little nervous because I was not really prepared yet. To simplify things, he will be referred to as OS2. OS2 took about 30 minutes to go over my films, re-checked all of my angles on my x-rays, and read my latest MRI. He was wonderful, I explained my long history to him. He did a clinical exam. He found that I had almost no IR and about 90' of hip flexion (I was having a really bad day yesterday). The test he did for instability was positive, but not as positive as he would like it to be. He would have liked me to have jumped off the table with that. I dont know what to think, I don't think I have "instability", I think it is "micro-instability", so I am not sure what that test should show. OS2 then suggested that it would probably be a good idea to call my OS...uh oh!!!! This was a 'top secret' appointment. I explained to him that my OS hadn't sent me, and didn't know I was here. He assured me that he wouldn't be upset, that he would actually be relieved to have help with this complicated case. I told him that what I wanted to do was hear what he thought and what he proposed, and then decide if he should call my OS. He agreed to that!

He thinks I have a loose body in the joint. He does not think that my labrum is too small at this point and he is recommending a scope to look around and try to fix things. He thinks an open dislocation is a huge deal and thinks that by trying a scope I am not burning any bridges, and if there is a possibility that I can be helped with a much smaller surgery, then he sees no reason to try it.

I decided to let him call my OS and discuss. And he did, while I waited!! They spoke for a while, and I patiently waited. When they finally got off the phone, OS2 called me into the room that he was in to discuss.

He said my OS agreed to do a scope, he wasn't too keen on the idea since it failed so many times, but OS2 pointed out that my left hip is awesome! So I should have scope potential! OS2 said that he still doesn't think my labrum is too small or should be causing me issues, but my OS fought him on that and said he has been in my hip 3 times and knows what it looks like and it is definitely too small. So he will put in an allograft to create a new labrum, re-repair the capsule, and...here is the kicker....they will do it together!!! OMG...I was laughing so hard, but I was so happy. I've never been happier being told I need surgery, but a scope vs open.....I am thrilled!!!

What A Long Journey This Has Been

2011-08-19T15:07:00.003-05:00

I definitely owe everyone a quick summary of what has been going on lately with my hip, but today is my 10th wedding anniversary, and all I can think of is that I have been dealing with my hip for half of my married life. It is making me very depressed.

To quickly summarize what has been going on, my OS really would like to avoid operating on me, for the 5th time. I can't blame him! So he is proposing we try something called ARP wave therapy. No one really can tell me what it is, other than a certain type of electrical stimulation. No one really knows if it will work but it can't hurt, so why not. I will hopefully know more about it in the next week.

In the meantime, I have decided to get a second opinion from another surgeon, an unbiased, no baggage, black and white, second opinion. I think that my OS and I have too much history for either of us to make the right decision at this point. If in the end I do need surgery, I will probably go with my OS, but I would like someone else to look at my films and tell me what they think. Someone who doesn't know me, and frankly, doesn't care if I have more surgery or not. The appointment is not set up yet, I left a message for his office staff.

In the meantime, I go through good days and bad days, and of course, this makes the process so much more difficult. If I always had good days, well, you wouldn't be reading about this. If I only had bad days, I wouldn't question anything. Its the good and bad that make me doubt everything, make me question everything, and quite frankly, are driving me crazy. There is no rhyme or reason at times either as to why I feel the way I do. I wore heels for a few hours yesterday without a bit of pain. I can actually usually wear heels and my hip doesn't hurt. It does feel awful in the sense that I don't walk well with them, I feel unstable, and my feet hurt!! I actually often have a sense of instability in my right hip, I try to avoid extending it fully when I walk by doing a strange rotation thing with my pelvis. Very strange!!

So the waiting game continues. I am waiting to hear more about the ARP wave, waiting to see if it works, waiting to get an appointment from my second opinion, and waiting to see if this will all go away, just as quickly as it came on!!!

Thinking and Worrying

2011-07-21T15:29:00.002-05:00

Since I had spoken to my OS on a Friday evening, I had to wait until Monday to really explore my options. The first thing I did was call the chiro to see if he was a good fit for me, and to see what his fees are since they do not take insurance. To make it short, sweet and simple, I hated him! He was arrogant, condescending and an all around asshole. There is no way I can work with someone like that.
I also have gone over the MRI report and gone over it again and again. I have discussed things with my husband to no end. He thinks I am being silly and stubborn and need to bite the bullet and agree to an open surgery. I think I am starting to agree, but the thought of it scares the crap out of me. TO scare myself even more, I watched a video of the procedure today....probably a very bad idea.
I emailed my OS because I have a ton of questions and think we need to address a lot of issues, mainly that I am freaking out!!!! Of course he has to be on vacation at the exact time that I am having an emotional breakdown, but I guess it doesn't really qualify as an emergency!
So I will "patiently" wait to hear from him, and go from there!!

MRI # 7 Report

2011-07-18T14:30:00.003-05:00

On the current examination, there is no occult fracture or osteonecrosis. No bulky synovitis is seen. There is however, marked attenuation of the iliofemoral ligament with some progressive hyperintensity in the interval since the prior study in 3/10 but overall residual discontinuity and poor tissue remodeling. There is considerable scarring of the synovium adjacent to the ligamnetum teres and this is progressive in the interval since the prior study. Effects of neck debridement are noted. There is high grade cartilage loss over the posteromedial parafoveal aspect of the femoral head extending focally down to the subchondral bone. Marked hyperintensity and high grade partial loss is seen anteriorly over the dome with progressive hyperintensity and partial wear since the prior study. No defined bone on bone contact is seen. There is intrasubstance degeneration of the superior labrum as well as degeneration of the anterior labral remnant but no defined split.

The hip abductors and short external rotators are notable for mild insertional gluteus minimus tendinosis. Insertional iliopsoas tendinosis is seen with a remodeled insertional partial tear. There is no atrophy of the iliacus muscle in the pelvis. There is no trochanteric or iliopsoas bursitis. No ischial bursitis is seen. Bilteral hamstring tendinosis is seen with a nonacute low grade partial tear affecting the semimembranosous origin on the right.

Subsequent quantitative MR imaging demonstrates prolongation of relaxation times, most strikingly affecting the parafoveal posteromedial aspect of the femoral head, some prolongation anterior medial dome with relative preservation over the superolateral dome.

Impression:
MRI of the right hip demonstrates features of instability with poor remodeling of the iliofemoral ligament and progressive scarring of the synovium, adjacent to the ligament teres in the interval since prior study 03/10. There is also progressive wear of cartilage with corresponding prolongation of relaxation times, as outlined above. Degeneration of the anterior labral remnant is noted without acute split.

Psoas Release...something to consider

2011-07-17T23:28:00.002-05:00

A few years ago, prior to my first revision surgery, I had an argument with my OS about whether my psoas tendon should be released or not. I, under no circumstance, wanted it released. He insisted that I should let him release it. I ended up not allowing him to, and 4 years later, we have this study. I do not have increased femoral anteversion, but I am having other types of instability and cannot imagine where I would be now if we had to add a lengthened psoas to the mix of issues.

Study Identifies Patients Who Should Not Undergo Surgery for a Snapping Hip Tendon New York—July 10, 2011

Researchers at Hospital for Special Surgery have identified a group of patients who may have increased difficulty for surgical treatment of a snapping psoas, a condition that usually develops because a teenager or young adult has a pelvis that grows faster than their psoas tendon. The study will be presented at the annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM), held July 7-11 in San Diego.

“The conclusion from this study is that you should be cautious about releasing the psoas tendon, particularly in cases where there is some structural instability in the hip, specifically increased femoral anteversion, because although the tendon may be causing pain, it is also providing some dynamic support to the hip so it can cause problems if it is released,” said Bryan T. Kelly, M.D., who led the study and is co-director of the Center for Hip Pain and Preservation (www.hss.edu/hippain) at Hospital for Special Surgery (HSS) in New York.

The study received the 2011 Herodicus Award given annually by the Herodicus Society at the AOSSM meeting for the best paper submitted by an orthopedic resident or sports medicine fellow.

The hip is a ball-and-socket joint where the head of the femur (thigh bone) rotates within the cup-shaped socket of the pelvis. The head of the femur is supported by an angled neck which joins to the long thigh bone. At the base of the femoral neck is a boney protrusion. The psoas tendon is one of two hip flexor tendons that attaches to this protrusion. When the pelvis grows faster than the psoas tendon, this tendon becomes tight and snaps over the pelvis during walking or other activity. This condition, which can be painful, is known as a snapping psoas tendon.

“The reason that it snaps usually has to do with the anatomy of the pelvis. We usually see it in adolescent hips where the pelvis is growing at a faster rate than the tendon can accommodate for the growth,” said Dr. Kelly. “Structurally the tendon is not long enough to accommodate the bony anatomy.”

Doctors usually treat a snapping psoas tendon with physical therapy that involves stretching and strengthening, anti-inflammatories and corticosteroids, but if this doesn’t work, doctors resort to surgically lengthening the tendon. Because the tendon does not have the ability to stretch, surgeons cut slits in the tendon in what is called a partial release of the tendon or a fractional lengthening. “You cut it in a way that allows the muscle to elongate,” Dr. Kelly said.

Studies have shown that arthroscopic and open surgery can achieve similar outcomes for this condition. Few studies, however, have studied whether abnormalities in hip structure, specifically femoral anteversion, can impact outcomes. In most people, the center of the femoral neck points toward the center of the hip socket. Femoral anteversion is a condition in which the center of the femoral neck leans toward the front of the socket. This causes the knee and foot on the affected side to rotate internally or twist toward the midline of the body.

In December 2006, HSS researchers started a prospective registry of all hip arthroscopy procedures performed during a three-year period, 2006 to 2009, by a single, high-volume arthroscopic hip surgeon, Dr. Kelly. The study presented at AOSSM included all patients who underwent a psoas tendon lengthening at the time of surgery, a minimum of six months follow-up, and a preoperative high-resolution computed tomography (CT) scan to detect femoral anteversion. Patients were not included in the study if they had previous tendon hip surgery or hip trauma.

Sixty-seven patients underwent arthroscopic lengthening of a symptomatic psoas tendon, either in isolation or in conjunction with treatment for hip impingement. CT scans showed that 19 of 67 patients had high anteversion. The researchers assessed clinical outcomes both before and after surgery with modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS) questionnaires. These are commonly used to evaluate a patient’s ability to carry out specific activities that involve the hip: activities of daily living, such as climbing stairs, and athletic activities, such as running and jumping.

Prior to surgery, patients who had high anteversion scored significantly worse in terms of athletic activities on the HOS, but there was no difference in either questionnaire scores in terms of daily living activities. After surgery, patients who had high anteversion scored significantly worse on the MHHS questionnaire with regard to athletic and daily living activities, but the HOS scores were similar between the two groups. Twice as many patients who had high anteversion had to undergo revision surgery.

The researchers say the psoas tendon may be an important stabilizer in the hips of patients with high anteversion, and the tendon’s release in these patients may result in a delayed return to activities after surgery and inferior outcomes.

“The results of this study indicate that there are certain groups of patients that respond very favorably to surgical treatment of the psoas tendon, but there are other groups of patients that due to mechanical reasons, surgeons should exercise extreme caution in proceeding with any tendon release around the hip,” Dr. Kelly said. He said these patients should be considered for alternative treatment strategies.

Other authors of the study are lead author and orthopedic surgery resident Peter D. Fabricant, M.D., and Katrina Dela Torre, R.N., M.Sc., at HSS, and Asheesh Bedi, M.D., former HSS fellow now at the University of Michigan.

MRI Verdict

2011-07-17T08:15:00.002-05:00

I spoke with my OS abt the latest MRI. We did a T2 mapping study to visualize the cartilage and get a better picture of the hip. He reviewed my MRI w the radiologist and says that there is no question that I have micro instability bc: 1) the ligamentum teres is torn (not sure if more torn since last surgery bc its the most difficult structure to image) 2) labrum is very small and can no longer provide suction to the joint 3) the anterior capsule is thinned out near the iliofemoral ligament, this is an area that was previously thickened (after the last surgery).
All of this is causing small, excessive motion in the joint. He is not 100% sure what is causing the posterior pain but says it is most likely the ligamentum teres. The cartilage in the back of the joint is a little thinned as well.
He wants me to continue to strengthen the muscles around the hip in order to provide stability to it. The only surgical option is an open surgery- which I told him makes me want to throw up! He knows I feel very very strongly abt not wanting more surgery. We did not get into details abt what he would actually do in said surgery, other than the fact that its a big deal and he has only done 5 of them before.
He is recommending I see a chiro who deals with musculoskeletal issues and treats professional athletes (not sure how he will feel about treating an everyday housewife :-) and does "different" types of therapies. I obviously don't need ART or any release work since I already have instability, and I looked up the chiro and all his techniques are release techniques...but I guess we need to try everything, and I know enough (and have a big enough mouth) to not let him do anything I think will make me worse.
So it's off to the chiro I go!!!!!

Micro Instability???

2011-07-07T05:31:00.003-05:00

I'm sorry that I haven't been updating my blog too frequently, it has been tough lately since a) I'm not really sure what is happening in my hip and b)I have very little free time.
I have been in PT for 2 months now and overall have not seen a change in pain level or symptoms. I'm pretty frustrated bc I was really hoping that this would be the solution for me. I saw my OS yesterday to review things again and decide what to do.
PT has been addressing the muscles, and trying to correct a muscle imbalance, I have not made progress :-(
My biggest issue is that I am having all this pain, off and on, yet my MRI shows nothing. To me, this is worse than if it showed a lot of issues, I feel like I am crazy!! My OS assured me that I am not crazy :-) and agrees that we need a better way to image this hip. He is recommending a new MRI with a stronger magnet that can map out the cartilage in the hip. He thinks that I probably have some micro instability due to issues in the capsule and ligamentum teres, and hopes that this new MRI will show something. He also thinks that my labrum is very small, so it is possible that it is no longer providing the suction in the joint that it is supposed to provide.

He explained that he looks at hips in 4 layers- 1) the muscles 2) the 'inert' labrum, ligaments, capsule 3) bony structures 4) nerves. He suspects my problem is with level 2
If you have read previous posts, you will know that me and MRIs do not get along. So I was not thrilled to hear that my first MRI was not of the greatest quality and that I would need another one....So to 'cheer me up' he gave me a rx for Valium for it!
He thinks that if the ligamentum teres is the problem, it will show some changes to the cartilage around the ligament.
If this is the case, then he thinks it would require surgical intervention...then he started talking about the possibility of an open surgery....at that point I freaked out....really really freaked out!!! I told him that I just couldn't discuss it right now, and that I thought the best thing would be to get the MRI first, then discuss it, if needed. He agreed and is happy that we are both on the same page, meaning wanting to avoid surgery at all costs.

Or Is It?????

2011-05-30T06:40:00.002-05:00

I am starting to have my doubts again....Over the last week or two, I have been having a gradual increase in pain. Is it because the honeymoon from my vacation is wearing off, or did my cortisone injection actually help more than I thought it did, or am I just plain screwed at this point?????

My new PT continues to address issues in my thoracic spine, ribs, abdominals, which are extremely messed up. I saw her last week, she barely touched my hip and worked a lot on my ribs, which are incredibly messed up, 2 are practically stuck together. She also worked on my thoracic spine and teaching me how to breathe. When I left, my hip was killing me. I thought it was so interesting since she barely worked on it.
What I am experiencing now is an irritation inside the joint when I try to work on hip flexion. I do it in quadruped with gentle rocking, and in standing, by hip hinging. When I try these, I end up with an extremely sore and angry joint.
I am also experimenting and seeing what happens if I only work on the hip or if I only work on the back...what will the hip do. So far both irritate the hip...so I am at a complete loss.

I saw my OS last week, and he agrees with me that I should continue to work with my new PT. He told me that he is finding a different type of problem in women. He called it acetabular-femoral impingement. When someone has regular FAI, in some people, the pelvis will tilt posterior to ease the pain of the impingement, and they end up with issues in the back, like on the hamstring etc. My conclusion is that I have the opposite, I have some sort of problem in the posterior side of the joint so my pelvis is tilting anterior, in turn, all of my anterior hip muscles are "freaking out". One thing my PT is very frustrated at times with is that my pelvis remains more anterior on that side, despite trying to hard to correct it. I am wondering if this is what I am experiencing. Definitely something to discuss this week.
My OS still cannot find anything really wrong with my MRI, which is good and bad! He wants me to come back in 6 weeks, but if things are not better in 3-4 weeks, he wants me to call him. I decided to ask a stupid question, what if PT doesn't help me...then what. He said he would want to scope it, to see what is happening......NO WAY. He promised me that he feels just as strongly as I do about NOT wanting to scope this hip...but it may be the only thing left to do. So....PT needs to start working really well ASAP!

Wow, PT is working!

2011-05-16T18:41:00.002-05:00

I have been to my new PT twice so far, but I am definitely more compliant with my exercises than I have ever been in my life. We (she) have discovered that my glutes have completely stopped working, my hip slides anteriorly, my ribs/ thoracic spine are really tight, all of my "large" hip muscles are working overtime and my smaller, stabilizing hip muscles are not working at all. Even if my ligamentum teres is torn, she thinks that by strengthening the proper muscles and getting the "wron" ones to shut off, I will regain my ROM and restore my pain free status.
One of he things I have been doing alot of is rolling on a tennis ball to release trigger points in my muscles. I am amazed at how tight and painful my quad is. It is by far the most painful muscle to roll out.
I still have pain with sitting but it is nowhere as bad as it used to be. I am definitely seeing a light at the end of the tunnel and am keeping my fingers crossed that this is what I have needed the whole time!

Taking a Different Approach

2011-05-03T05:40:00.002-05:00

Sorry if I left you hanging! I was on vacation for 10 days and as usual, incredibly busy with life at home. The good news is that while I was on vacation, I felt great, after a few days in sunny Florida where I did absolutely nothing, my pain started to disappear. Once I got home, it slowly started to come back, which leads me to the conclusion that I should retire now!
It is not as bad as it was before I left and I can tolerate sitting which is a huge plus. But I have decided that I need to do something, and everything that I have been doing is not working, and no one that I have worked with knows how to help me, and my brain has shut off regarding this. So I found myself a new PT. I definitely feel that I am cheating on my old PT, but since I wasn't getting better, I needed to move on.
I saw my new PT yesterday. It is a totally different experience than my old PT, who ran his office similarly to the way my office runs. Chaos, patients everywhere, running around from one patient to another. My new PT only sees one patient at a time, the office reminds me of a spa, I walked in to absolute silence. A completely different experience than I have ever seen at a PT clinic. I gave her my ridiculously long hip history, which took up most of the session!!! She found a lot of dysfunction in my back, it is stiff and I don't move well. Also instability and weakness in my hips. Surprising to me, she found a lot of tightens in my upper back and she thinks that those restrictions are what is causing my hip and SHOULDER problem. I am definitely getting a bang for my buck!!! As she started releasing restrictions in my upper back, I don't think I have ever experienced such pain before. But then she re-checked my hip flexion and I had gained ROM. She then checked my abdominals and found a lot of restriction in my external obliques. She also said my rib cage was tight. So she worked on releasing restrictions there, ouch. Ounce again, my hip flexion ROM increased. It was pretty incredible, something I had never thought of.
I am going to try to see her 1x/week, I have appointments set up for the next 6 weeks. It is pretty far away and she doesn't take insurance, but I think that if she can help me, it will be priceless.
My homework is the continue to work on releasing restrictions in my abdominals, and try to expand my ribcage. Also quadruped rocking to maintain my hip flexion, and learning to breathe properly with diaphragmatic breathing.
Keep your fingers crossed that this is the solution!!!

Video Presentation on the Ligamentum Teres

2011-04-17T18:11:00.002-05:00

During my "research" today, I came across this: More than 120 physicians from around the world gathered in Vail, Colorado on March 17–19 for Smith & Nephew’s 5th annual Vail Hip Arthroscopy Symposium. The three-day educational event was led by Marc J. Philippon, MD, managing partner of the Steadman Philippon Research Institute. Link to Symposium info The focus of the symposium shifted to “New Procedure and Unique Cases” on Day Two. Richard Villar, FRCS, Spire Cambridge Lea Hospital, UK, opened the session with a presentation called “Ligamentum Teres: The Forgotten Ligament.” Mr. Villar described the three classifications of ligamentum teres injuries; Type 1 (complete tear), Type II (partial tear) and Degenerative (not torn but not functioning). Treatment options include removal (with RF or shaver) or reconstruction. Mr. Villar reached the following conclusions:  The ligamentum teres is likely to have a function; do not ignore it  Arthroscopic surgery (of whichever sort) appears to work  The ligamentum teres may have healing potential Video

PT...Again

2011-04-17T09:48:00.002-05:00

I had my latest PT appointment on Thursday, it was incredibly disappointing. I guess I am looking for a miracle and there really isn't a miracle out there at the moment. I said to my PT "so, he didn't know what to do with me so he dumped me on you", he agreed!!! He is at a loss, pretty much, and with his expertise, if he is at a loss, I am screwed!! He said he wants to treat it like an ACL/PCL injury in the knee, where all the stabilizing structures are gone. So we started with some gentle isometrics and proprioception exercises. I am going on vacation tomorrow so will continue to do them while I am away and see him when I get back. In the meantime, I deiced to explore some other options and contacted another PT who may have a different kind of approach. I am going to see her at some point as well when I get back from vacation. I hope she is more optimistic and can help me, bc I don't know how much more pain I can take at this point.

The Latest Appointment, Still No Answers

2011-04-13T06:29:00.002-05:00

I saw my OS yesterday...he still doesn't really know what's going on. His best guess is that ligamentum teres is torn, which is why I am having so much posterior pain and so much trouble sitting, and that the capsule got stretched out, which is why I am having muscle spasms, to try to stabilize the hip. I have a lot of clicking going on, he initially said its prob psoas but then he actually heard it and said it is not psoas, sounds like intra articular clicking, maybe ligamentum teres...bottom line is he said avoid doing it! He also said that he was actually really upset that I had relief from the cortisone injection since it does mean that the problem is coming from the joint, he was hoping that it wouldn't help at all and we could address things outside of the joint. We discussed the drugs I have tried so far, Celebrex made my Crohn's disease flare up, and Ultram made me dizzy and crazy. "Lucky" for me, I brought J along with me for "support", my OS wanted to know how Ultram made me crazy, "basically, it turned me into a psychobitch", to which J added "well, it was hard to tell the difference from how she normally is". Thanks J, really appreciate the support :-) I made him compare my 2 MRIs side by side, to actually see if there was a change in the capsule, they both looked pretty good (one from this month and one from last year), so he doesn't think the capsule is actually torn. He wants me to go back to PT, gave me Baclofen for the muscle spasms, and see what's happening in a few weeks. He also wanted to give me a medrol dose pack for the pain but we ended up agreeing that it wasn't what I wanted bc of the very remote possibility that it can cause AVN. He wants me to be patient and try to work through it w PT and see what happens! When I came out of the room his PA was there, so I said to him "he basically has no idea what is going on", and he told me that my OS studied my mri so hard, trying to see a problem. "I guess I have really photogenic hips" I said So that's the story!

Turning Point

2011-04-10T07:43:00.002-05:00

Last Friday was definitely "rock bottom" for my latest hip saga. Things began turning around this past week, I think I was wrong about the cortisone and it is finally kicking in, it took its sweet time but yes, I began feeling its effects mid week. Most importantly, sitting is not excruciating anymore. The best days were Wed and Thurs I think, I had absolutely no posterior hip pain at all, I had some groin pain those days, but I did well physically and emotionally. Friday was not as good as Thursday and Saturday was not as good as Friday, but I hope to continue to get some help from this latest injection. Yesterday I had an event to go to and I had to wear heels. I had no pain while wearing them, but I just did not feel good about it. My hip could not handle the heels and the joint just felt "slidey", like it could not control my leg in the shoes. Ironically,I came home and put on sneakers and had a ton of pain, go figure!!! As I sit here writing this, It is getting a little difficult to sit. My husband keeps telling me to "stop thinking about it", but how can I not, I am still nervous, and I am still in pain. I see my OS on Tuesday, stay tuned for an update Tuesday night!!!

And The Saga Continues

2011-04-03T07:52:00.003-05:00

Monday was my cortisone injection, Tues-Thurs were a little bit better. I went for a session of reflexology on Thursday afternoon, since it usually helps relax me, and my nerves have been shot lately, Ive never had so much anxiety in my life. I was speaking to the massage therapist about my "issues", and he thought I should get a massage. My muscles are in horrible spasm, I kind of wanted a massage but was scared of getting one because in my mind, the muscles are in spasm for a reason. I texted my PT, he said to ice and tape my hip. I really cant tape it on my own, and I cant stay in bed all day with ice. I texted him again on Friday morning and asked if I should just get a massage to ease up the spasm. He called me back and said that a deep tissue massage would be a bad idea, but a lighter massage may help. I told him that if one more person at work asked me if I was ok, if I should be working, if I should be doing this, I was going to scream. He gave me permission to punch the next person in the face :-) He also, again, said I need pain meds! So he called my OS office and I got Ultram. I took one Ultram late Friday afternoon, it helped with the pain but not fully. so I decided to take another. Bad idea. I could barely get off the couch, I was so dizzy and lightheaded for the rest of the night, and I didn't sleep well. Saturday I took 1/2 of a pill and was less dizzy, but dizzy nonetheless. The good thing is that for me, a little goes a long way and it has really helped my pain. I don't want to take one today because it is L's b-day party in the afternoon and we have a lot to do, and I don't want to feel like crap. Icing also goes a long way for me, unfortunately its hard for me to find time to do it. The second I lie down with ice my kids either need my ice, need me to get up and do something, or decide to jump on my leg.

Hip Injection #8...done

2011-03-29T05:48:00.002-05:00

I was able to get in for an injection yesterday afternoon purely by the grace of G-d...and maybe a little begging on my part to "please take me out of my misery"!! Driving down I could barely sit, the posterior joint pain and lateral posterior pain (what I believe to be ischiofemoral impingement (IF) was really awful. Before I had left my house, I tried some pain provocation tests so that I could have a baseline and a before and after. I did a lunge with the left leg in front and on a stool, some impingement tests and some other movements of the leg. The injection was more painful than I remember it ever being, probably because I have scar tissue built up in there. Before the injection the radiologist tried to provoke pain, he did some FAI tests and they hurt in the groin, he could not reproduce the posterior pain but I explained that I had been able to earlier. He told me to check those maneuvers out again later. I said if I could drive home without pain I would be thrilled!! After the injection most of the tests he did provoked no pain anymore. I limped back to my car, sat down and panicked...the back of my hip still hurt. After a minute, I guess the drugs made their way back there and posterior pain was GONE! I drove home comfortably and happy. The IF pain was still there but without the posterior joint pain it seemed a lot more manageable. After 3 hours my "honeymoon" was over and the pain hit hard. When the kids were finally in bed I was able to ice for about an hour. I then decided to go to sleep but the pain was there so I went back for the ice and ended up falling asleep with it on until I woke up 3 hours later! This morning I think the posterior pain is better, the true test will be when I get into the car in an hour! Keeping my fingers crossed

Why Why Why

2011-03-25T14:16:00.002-05:00

Thurs morning after PT I was in the car and using the "water bottle trick", after about 2 minutes I began having anterior hip pain. When I got out of the car my psoas/ iliacus were in spasm. That's when I began to freak ot. I texted my PT with a desperate message. He called me back, said to stop doing that bc it was causing my femur to be pushed anteriorly and making the psoas try to stabilize it. He also said I needed to get my pain under control ASAP, I coldn't sit down. So I tried to get in touch with the OS office.....
Yesterday I iced, took Vicodin, Motrin....Was in a lot of pain. I was up in the middle of the night icing and medicating...its been rough.
I finally spoke to the PA today, he called in Celebrex for me and I am going to try to get a cortisone injection next week into the joint to calm things down. He said the psoas is going into spasm to stabilize. I don't like this one bit.

Still No Answers

2011-03-23T18:19:00.003-05:00

I got home from PT last night with more questions than answers. My PT thinks the hip is loose and and lax,this is about all I got. I am also really weak in the glutes, he is not sure if it is a straight out weakness or if they re inhibited by pain. The rest kind of went in one ear and out the other. I am so overwhelmed with all of this that I cant even process anymore. He thinks there may be a coverage issue somewhere (don't ask me where) but I could be getting pinching from some sort of impingement posteriorly. Honestly, this is all too much for me to handle. I was doing a lunge yesterday (just to demonstrate for a patient) with the good leg, the bad leg was behind me, in extension. This set off so much pain I think I saw stars and almost passed out in the middle of my office. My PT wanted me to try that with a posterior pelvic tilt and an anterior pelvic tilt to see if one was better, I was too scared to reproduce that pain again that I couldn't do it. He thinks I may need a stress test to check for laxity in the hip, I'm not sure what this would accomplish, or what it entails, I was too scared to ask.
In the meantime he gave me one exercise to do at home, a standing hip abduction with my hip in IR. He also told me to put a small water bottle under my thigh near my butt when sitting to make sitting less painful, it takes the pressure off of the ischial tuberosity.
And so the roller coaster ride begins, and the psychosis, paranoia etc. Because there will be days when I have no pain at all, and days that are excruciating, and it will drive me up a wall!!

It's Official, My Shoulder Officially Sucks

2011-03-21T21:23:00.002-05:00

Tomorrow will be 2 weeks since I had my AC joint injected and my pain is back full force. I guess I was dreaming when I had hoped to get 6 months out of this latest injection. I don't know what to do now, But working is killing me. I had someone in my office work on it today, I got a whole 90 seconds of relief...so not worth it!!!

Hip MRI #6...done

2011-03-16T19:17:00.002-05:00

Yes, I had yet another MRI on my hip. Last week my x-ray was fine, over the weekend I was able to ice and rest and was feeling better. Monday the pain was back with a vengeance. I freaked out and emailed the PA from my OS office. He said to have an MRI and come in today.
Since this latest "episode" of hip pain started, I have been having a ton of anxiety and been having trouble eating bc I am so scared. I took (my first ever) Xanax on Monday night. this morning I woke up at 3:30 with my heart racing and my stomach in knots. By 5:30 I decided to eat something since my stomach probably hurt from lack of eating. By 6:30 my heart was still racing and I felt like I was going to throw up. Xanax #2 was a god send. It totally calmed me down and took the edge off. The MRI was almost relaxing!! It was the first time I was able to rest with no kids calling me, no blackberry, no work!!

Right after the MRI I went to see my OS. I explained what happened, and that I was having posterior joint pain. He looked at the MRI, the labrum and capsule were fine, thank goodness. There seems to be a little abnormality at the ligamentum teres, which could cause posterior joint pain. there is also irregularity at the quadratus femoris, which is what can get impinged with ischiofemoral impingement. I have not done all that much research on ischiofemoral impingement but I guess that will be on my to do list. It is an extra-articular impingement, he thinks its possible that bc I have some more motion now that that is getting pinched. But, I have pain in the joint with internal and external rotation, which leads him to believe it is being caused by the ligamentum teres.

The plan is to keep trying to ice and rest, go back to PT, in 2 weeks if its not better then we can discuss an injection. Where? I'm not really sure, but I'm hoping that PT can help decipher where the pain is coming from, and better yet, eliminate it to avoid an injection.
When I left his office, I was feeling better, less anxiety, but later in the day the pain got bad again and all of my anxiety came back....I don't know where I am going to find the strength to deal with this...again

##$%#&* Right Hip

2011-03-10T18:37:00.002-05:00

Ok, so if you read the yahoo group postings yes, I am having hip issues again. At first I was having throbbing in my hip at night mostly. The pain started getting worse, it was radiating to the side of my hip, the back of my hip and down my thigh. It was for the most part groin pain though. I was trying to stretch it and stretch it since it is tight in the front still, and at times it bothers me that it is so tight. Yesterday, i was stretching it and got a good pop, which is not abnormal for me, when I had it in external rotation. Since then, I have a lot more range into ER, but when it gets to endrange, I have pinching in the back of the joint and behind the greater trochanter. I also have a ton of posterior hip pain, all the time, it hurts to sit down which is really hard for me.
I had an xray today, and of course I had no idea what happened to me (it wasn't until later that I was able to clear my mind and and remember these events, and even now, I'm not 100% sure if this is the issue). Thank goodness the xray was fine, no fracture or infection, which was a big concern of mine. As of now, my butt really really hurts, and ER, which used to be my position of comfort, is not uncomfortable. I am limping at times....this stinks.

Hopefully hopefully hopefully, it was popping of scar tissue, and now there is localized inflammation and it will pass in a few days. I will keep you posted!!!

The Good and Bad News

2011-03-08T21:14:00.002-05:00

I had been putting off going back to my shoulder doctor for fear that he would want to order an MRI. The good news is that things looked bad enough on x-ray so an MRI is not needed. The bad news is that I am practically bone on bone in my AC joint and he is recommending a distal clavicle resection. It does not need to be done now, he did give me another cortisone injection, but warned me that I cannot keep having them, and I will have to have it 'fixed' sooner rather than later. I am hopefully going to get a long stretch of relief from this injection and not have to think about this for a while.

Popping In To Say Hi

2011-03-05T18:49:00.004-05:00

I haven't bothered anyone with my woes lately, life has been busy, the kids are 6,5 and 2, and getting big! My left hip as always, is perfect. My right has been once again giving me some trouble, I'm not sure exactly what is going on, I see my OS next month, so we will find out then. My shoulder is a mess, I see the shoulder OS on Tuesday, hopefully for another lovely dose of cortisone!!! I just wanted to add a few cute pics of the kiddies and day hello!

New 2011 CPT Codes for Hip Arthroscopy

2011-01-22T18:28:00.000-05:00

◦29914 – Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)
◦29915 – Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)
◦29916 – Arthroscopy, hip, surgical; with labral repair

Aetna and FAI 2

2010-11-19T06:33:00.002-05:00

A few months ago a fellow hipster sent me a post and asked me to publish it on my blog. It was about Aetna and their refusal to cover FAI surgery. That post generated many replies, including the one below.
This is a response from Aetna:

The date on our website is not the date that the update will be published, but the date that it will be discussed by our Clinical Policy Council. All updates have to go through a subsequent review, approval and implementation process. We expect the update to be published by the end of the year.

Should you have any questions or concerns, regarding these policies contact provider of services dedicated lines; Indemnity and PPO- based benefits plans 1-888-MD Aetna (632-3862) for HMO benefits plans – 1800-624-0756. Our Provider Service Representatives are trained to specifically handle any concerns you may have.

Also, for your convenience any future concerns or questions regarding our policies can also be faxed to us at 859-425-3379.

November 18, 2010 11:56 PM

Below is the original post:
Sent to me by a fellow hip friend:

Aetna’s assessment of FAI is archaic and asinine!

As you all are aware, our cause for UHC’s coverage of FAI was very successful including a NY Times article and many reversed appeals in favor of the patient. UHC along with other major insurers (BCBS, Cigna, Kaiser) now covers the arthroscopic treatment of Femoroacetabular Impingement.

Unfortunately, Aetna still has not caught up with the times. Many of our fellow patients have been successfully treated with hip arthroscopy and have been able to move on to enjoy active lives. People that are insured with Aetna are being discriminated against IF they also have a diagnosis of FAI. Aetna has taken the position that the use of the hip scope is unproven and/or experimental. This is absolutely ridiculous. It is very obvious that the bottom line is that it IS a covered procedure by the other insurers so how is Aetna’s non-coverage of this procedure accurate?

Aetna would rather have a young active patient become so disabled that their medical situation deteriorates to the point of needing a total hip replacement with all the associated medical risks and financial costs. Take the example of your typical patient. Young, active 30 year old Aetna consumer who is denied access to treatment for FAI. Based on Aetna’s opinion, the patient will go untreated for years UNTIL the patient requires a total hip replacement. Of course, doctors won’t typically do a THR on someone under 60 so this patient has to wait 30 years for treatment because of Aetna’s inaccurate and woefully pathetic position on FAI treatment.

Mr. Ron Williams (CEO of Aetna) when is Aetna going to catch up with the peer reviewed literature and your peers? When is Aetna going to reverse the policy so that your clients that need this surgery will have the same rights as patients that have UHC, Cigna, BCBS and Kaiser? When will Aetna decide that they would like the “A” in Aetna to equate to “Amazing” instead of “Awful’?posted by Susie at 7:47 PM on Sep 28, 2010

Double Update

2010-11-09T05:34:00.003-05:00

Hip: I had an appt with my hip OS a few weeks ago but haven't had a chance to post yet. I am almost 1 year out from my last (4th) hip scope and very pleased with the results. I have no pain at all in my hip. the only residual effect from that surgery is that my hip is really tight and still catches and pops quite often. I don't care though, I will take that over groin pain any day. My OS explained that during the capsule tightening procedures, sometimes they make it a little too tight, he recommended more PT to keep it loose, since that is what I do when it gets bad, but he would like me to take a more preventative approach with PT and go before it gets bad. In theory, that is a wonderful idea, in reality, who has time for more PT!!! He also offered me a cortisone injection into the capsule, which I politely declined as well...no more hip injections for me! I will deal with this!

Shoulder: It has been 2 weeks since I had the AC joint injected and I am thrilled with the results. The joint does not hurt at all anymore. Although I still get some pain around the area sometimes, It is tolerable. In a very "susie-like" fashion, I requested the OS office note and the radiology report on my x-ray...OS suspects AC joint arthritis, if the injection doesn't help he will order an MRI to rule out osteolysis, which is not a common problem in 30 year old housewives!!!! (ok, I work too, but still...), it is more of a weight lifter issue, and the only weights I lift are 40 lbs toddlers and pots and pans!!!!

Cost of Hip Arthroscopy has been updated

2010-11-01T18:37:00.001-05:00

http://susie711.blogspot.com/2008/01/cost-of-hip-arthroscopy-and-its.html

Surgery # 4 numbers have been added...1 year later!! Life has been pretty busy!

Cortisone Injection # ?????

2010-10-26T18:05:00.003-05:00

As I had hoped, my "new" OS gave me a cortisone injection. He agreed that whatever my issue is, it is coming from my AC joint. He is not sure what or how I injured it since there was no trauma, but he thinks that given my line of work, it is not too shocking. My x-rays were good, no arthritis or separation, he thinks that it is just a local inflammation and hopefully the cortisone will knock it out.
Most of his pain provoking tests referred pain to the front of my shoulder, at the AC joint, and there is tightness with horizontal adduction. I am pretty sure the cortisone in working, I felt no pain right after which is good since he used some local anesthetic with the steroid when he injected.
I hope to continue to report improvement with the shoulder!

Shoulder...

2010-10-25T05:55:00.002-05:00

As my shoulder issue continues to be an issue, I am happy to report that I finally took the time to listen to what my body was telling me and self diagnose!!! I do not have a labral injury or a rotator cuff injury, rather, an acromioclavicular (AC) injury, or, a separated shoulder. Whats funny is that this is usually caused by trauma or a direct fall onto the shoulder....but not me, I just 'develop' these issues! Since it does not seem to be getting better, and I am having trouble sleeping at night and difficulty working, I made an appointment with a shoulder specialist. What a breath of fresh it air to deal with his office...I called Thursday and was given an appointment for Tues...5 days later....I think I waited for my first hip appointment 4 weeks and currently people are waiting 6 weeks or longer to see my OS. So I will hopefully see him tomorrow, hopefully he will give me a cortisone injection and I will be on my way!!!

Massage...Ahhh!!

2010-10-17T06:29:00.002-05:00

I went for a 1 hour massage on Tuesday in hopes of leaving a little more relaxed and in less pain. The massage therapist asked if I had any "problem areas", so I told her my right shoulder had been bothering me. She said she would focus a little more on it while she worked.

So the massage began and she began working on my scapula and upper trap, "wow", she said, " this is really bad". She continued for another few minutes, and then said "I think I can spend the entire hour on this shoulder, if you want, or I can leave it if this is too painful for you and do the rest of your body". I told her to just do the shoulder. It was excruciating, every spot on the entire upper right quarter of my body was so painful. There were knots everywhere, she used her elbow, she was dripping sweat halfway into the massage. After the hour was up, she said that it looked better, definitely lower and softer, but she could spend another 2 hours on it if she had the time.

The rest of the day and into the next day were really painful. It hurt to touch the area. By Thursday night it was beginning to feel better. I have had a lot less pain in it and am able to use it more than I was. I am hoping that it was a big muscular issue and I won't be dealing with it anymore. I will keep you updated since I still continue to have pain at night and some of the surrounding muscles still hurt.

Running...Again

2010-10-14T09:59:00.004-05:00

I decided to give running one more chance, how bad can it be, I already had 4 hip surgeries, hurt my ankle, peed all over myself and hurt my shoulder...does lightning really strike twice????

So....most importantly, the pelvic floor exercises really worked, no more incontinence on the treadmill!!! This was the main reason I hadn't gone back to running. It was a huge concern of mine and luckily I was able to take care of it. The hips and ankles did great as well. Unfortunately, running bothered my shoulder.....strange as it sounds. At about 22 minutes I gave up completely on running and stuck to walking, I guess the pounding and vibrations seem to upset it too much.

Shoulder Update

2010-10-11T05:42:00.000-05:00

For those of you with shoulder issues, please chime in and tell me if any of
this is familiar. I have pain on and off, sometimes I am 100% pain free, other
times I am in agony. I can do anything with it, but will immediately know if I
shouldn't have bc it will hurt. Nights are the worst, sometimes I can't sleep it
is so bad. The pain is usually right at the top/front of the shoulder but will
radiate to the back of my scapula, down my biceps or triceps and into my upper
trap. I guess it depends what I do and how I compensate. I ice, I heat, I
Flector, they help but the pain come back. I am trying to strengthen my rotator
cuff but it is painful and I usually have more pain later in the day when I do.
My ROM is starting to feel limited at endrange, so I am stretching it daily.

So...those are my symptoms. I have also done acupuncture and moxa, acupuncture
didn't help, moxa may have, I just did it last night so the jury is still out. I
just want a quick fix and for the pain to go away!

Shoulder Now.....Please Make It Stop

2010-10-06T05:42:00.003-05:00

Very interestingly, a few weeks ago, it was brought up on the FAI yahoo group that many people on the list who have had an acetabular labral injury have also had a glenoid (shoulder) labral injury. While the anatomy of the 2 is very different, the hip is an inherently stable joint and the shoulder is an inherently unstable joint, I found it odd that so many people had both issues. I don't think there is a relationship and I doubt that so many people have any underlying soft tissue pathology, but who knows. Honestly, I think that it has to do with the fact that these types of injuries occur in young and active populations. I didn't think much of it until about 3 weeks ago when my shoulder began hurting...alot.

For the past several months, I have had pain at the top of my shoulder and my upper trap, I attributed it to stress and promised myself that I would schedule a massage. Of course I never found time for a massage so continued to suffer. It was especially bad at night, so I attributed it to my pillow and switched to another one. That didn't help. The pain then travelled into my shoulder joint, into my biceps and posterior scapular muscles. It hurt at rest, more at night, felt weak, at times it is difficult to hold a glass of water or coffee cup. I can do everything with it, and it usually doesn't hurt while I am doing it, but will hurt right after. It feels weak but I cannot pinpoint one spot where the pain is, it is an entire area. The last 2 nights I have slept with a Flector patch on it and it seems to be helping.

Just as the hip issues were beginning to clear up, this happens. I am at a loss with this and don't know what to do.....

Aetna and FAI

2010-09-28T19:47:00.002-05:00

Sent to me by a fellow hip friend:

Aetna’s assessment of FAI is archaic and asinine!

As you all are aware, our cause for UHC’s coverage of FAI was very successful including a NY Times article and many reversed appeals in favor of the patient. UHC along with other major insurers (BCBS, Cigna, Kaiser) now covers the arthroscopic treatment of Femoroacetabular Impingement.

Unfortunately, Aetna still has not caught up with the times. Many of our fellow patients have been successfully treated with hip arthroscopy and have been able to move on to enjoy active lives. People that are insured with Aetna are being discriminated against IF they also have a diagnosis of FAI. Aetna has taken the position that the use of the hip scope is unproven and/or experimental. This is absolutely ridiculous. It is very obvious that the bottom line is that it IS a covered procedure by the other insurers so how is Aetna’s non-coverage of this procedure accurate?

Aetna would rather have a young active patient become so disabled that their medical situation deteriorates to the point of needing a total hip replacement with all the associated medical risks and financial costs. Take the example of your typical patient. Young, active 30 year old Aetna consumer who is denied access to treatment for FAI. Based on Aetna’s opinion, the patient will go untreated for years UNTIL the patient requires a total hip replacement. Of course, doctors won’t typically do a THR on someone under 60 so this patient has to wait 30 years for treatment because of Aetna’s inaccurate and woefully pathetic position on FAI treatment.

Mr. Ron Williams (CEO of Aetna) when is Aetna going to catch up with the peer reviewed literature and your peers? When is Aetna going to reverse the policy so that your clients that need this surgery will have the same rights as patients that have UHC, Cigna, BCBS and Kaiser? When will Aetna decide that they would like the “A” in Aetna to equate to “Amazing” instead of “Awful’?

Hip Issues and Incontinence

2010-09-03T14:12:00.002-05:00

If you are thinking this is TMI, then I suggest you stop reading. As usual, I have no problem discussing the things that no one else wants to.
When I initially had hip pain, over 3 years ago, one thing In noticed was that I had to do a pelvic floor muscle (PFM) contraction, or kegel, when I would cough or sneeze. I never actually leaked urine but felt that I was going to. With regular PT, this got better and I forgot about it. Last week I was doing jumping jacks with L when I suddenly leaked so much urine that it was running down my legs. I was shocked. I not only had never actually leaked urine, but this was a huge amount, and completely out of the blue. I have been having a lot of tightness in my hip, and even had to go back to PT yesterday for a "tune up", but I see no other reason for this.

At PT, my PT loosened up the anterior capsule for me and sent me on my way, encouraging me to go back to running to keep the hip stretched. I did, last night I got right back on the treadmill and began running. I started feeling leakage again and couldn't believe it, I was leaking urine again. Now, jumping jacks I don't do on a regular basis, but running...I never ever had a problem with running. I am totally freaked out by this. My only saving grace is that I was home both times. Yes, I ahve had 3 babies, 4 hip surgeries, but urinary incontinence is NEVER normal.

So, what am I doing about it? PFM exercises, and more PFM exercises. Kegels when I remember, plus hip adduction (squeezing a ball in between my knees) and hip ER/abd with a theraband around my knees. I am going to do them aggressively, I won't be running for a while because I will be travelling a lot in the next week and a half, but hopefully when I get back things will be strong again and I wont have this problem anymore.

Checking In

2010-08-18T05:49:00.002-05:00

Wow, what a slacker I have been! The truth is that I turn to my blog when things are not going well, and well, for the most part they have! I am not running at the moment bc it was bothering my hip, but between you and me, running is probably stupid and I shouldn't be doing it. I also just left my job of 5 years, but decided I wanted to try my new job before quitting, so for a period of time I was at 2 jobs. I am now back down to one job and feeling a lot more calm. As far as my hip goes, it has been tightening up, and the capsule gets caught on something and I experience a lot of clicking. It also gets stuck sometimes and will pop loudly when it finally gets unstuck. I should go back to PT for a "tune up" but haven't had time! I will see how things go, and now that I have more time I will go back to running again, and see how I feel!

5K Training...taking a break :-(

2010-07-07T05:53:00.002-05:00

My 5K training has been going especially well, I a quite impressed with myself since I have never been a runner before but mentally really needed something to get me out of the "hip slump".
Last week I ordered a pair of Fit Flops thinking they would be great to help tone up my legs. Well....they were anything but great. I developed horrendous ankle pain, right worse than left. My right ankle is so swollen and painful that there are parts of the day that I think I have a stress fracture. I was wearing socks at Pilates yesterday and the swelling began hanging over the sock...gross!! When I first wake up it feels ok but as I start walking on it I feel it begin to swell and the pain comes back with a vengeance. It obviously doesn't help that I am on my feet the entire time that I am at work. I am hoping that this will go away on its own...not in the mood for doctors and x-rays :-(

When in Doubt, Find An Experienced Surgeon

2010-06-27T06:33:00.002-05:00

When I had my appointment with BK, we did some talking about why my surgeries failed and what he has learned, and why his surgeries no longer fail. Unfortunately for me, I got injured 3 years too early. Lucky for everyone else, he too has (and the other "big names") changed his technique. For starters, I could have avoided revision surgery #1 bc now he ALWAYS takes down cam impingement in women. He has found that addressing just a pincer is a big mistake bc women for the most part have larger femoral heads, by doing a rim decompression the problem is just exacerbated. I could have avoided revision #2 bc he now ALWAYS closes the capsule at the end of the surgery, way back when, it was left open. Some lucky few of us subluxed our hips and required the capsule to be tightened (hence the capsular shift I most recently underwent).

What I thought was so interesting was that he was able to just look at my plain x-rays and see that my left was done with the old techniques, and the right with new techniques. He has taken some bone down in each surgery and the final result is a "perfectly shaped" hip on the right! The left looks good, but not quite as "beautiful" as the right, despite the fact that the left NEVER gives me trouble.

"The Recommendation...And What I Am Doing About It

2010-06-21T07:39:00.000-05:00

I have been having episodes of groin pain and tightness, definitely better than
a few months ago, but still making me crazy anyway. I just don't want to deal
with it anymore. I saw BK last week, my x-rays look great. Actually, my multiple
scoped hip looks fantastic angle-wise, my single scoped hip doesn't look 'as
perfect' to him, but it is perfect to me! He thinks I should go back to PT to
address my lingering tightness and pain. I agree, but.... I really don't want to
go back to PT! I love my PT but at almost 8 months out, I don't want to continue
or go back. I have decided to work on it on my own and in my craziness I am
starting a 'couch to 5k' program tomorrow. I desperately want to get into an
exercise routine, and have a goal, and be excited to do it. I think this is a
good way. I really hope this won't make my pain worse or my capsule tighter. My
plan is to start tomorrow, if all goes well this week then I will splurge on a
good pair of running shoes next weekend. J is training with me and I think I
convinced my parents too!

Hopefully this can get my past the latest bump in the hip journey!

Am I Micro Managing?

2010-06-04T05:03:00.002-05:00

Am I being crazy and unrealistic? Wed I knew I was in for trouble, since I had to go do a presentation at L's school. her school is built on the side of a hill ( a very steep hill). Getting there was no problem, since her classroom is close to the bottom. Coming back up was quite an adventure. I still have a lot of trouble walking uphill. That night I had a ton of pain which I wasn't expecting, and made me quite mad!! I really don't think I should be dealing with pain like this at this point, and quite frankly I need this hip to start behaving!

Time Flies When You're Having Fun...

2010-05-30T06:47:00.002-05:00

...Or not!! So once again, it has been a roller coaster of issues with my hip. It is a lot better than before I began this round of PT, the capsule is a lot "looser" and is not getting stuck as often. It does often click or pop. A lot of time I will be trying to shave my legs and the leg just wont externally rotate, it then pops, and is then able to rotate. Weird. What bothers me is that I still get pain in the joint and I don't know why. It is not excruciating, I don't take anything for it, I don't even use the Flector patches on it anymore, I have just gotten used to it I guess. I am at the point where I just give up, at lest for now. I don't think there is anything else to be done at this point, and many people need up to a year to feel better, so maybe I need to have a little bit of patience and wait. This is easier said than done, bc at 29, I don't want to have pain when doing simple activities, like cleaning out my closet, taking the kids for a walk (yes, these are all activities that cause me pain), but I have resolved to "chill out" and give it some time.

My crazy work schedule is coming to an end in 2 weeks, thank goodness, so we will see what happens. I had PT this week, and he managed to really loosen up my hip, and get me to have normal stride length. This lasted a total of 4 minutes. Once I was back outside, walking the streets of NYC, I had pain, which was incredibly frustrating. I have an appointment with BK in a few weeks, mostly to get an x-ray and make sure the bone is where it needs to be. I called about 2 weeks ago (middle of May) to make an appointment, the receptionist asked if I was in pain, I said yes. She told me she would try to "squeeze me in", "how's June 22nd". Seriously!! The truth is that it doesn't even matter bc there is nothing to be done, or at least that I am open to doing (injections, drugs...), but she managed to give me June 15th! I will try to be better about updating my blog, but work is sucking the life out of me!

Yes, I Won My Appeal

2010-05-12T11:14:00.002-05:00

Lately I have been receiving comments on older posts asking if I won my appeal. Yes, I did, my surgery was completely covered :-) Thanks to all who have helped me with the appeal as well as paved the way for me and others to have our surgery covered (especially MC)!

A few weeks ago, I had a 20 minute "hole" in my day and was actually able to leave my office for the first time in the middle of the day since I began my new hours. As I was walking out, I realized I had a voicemail from BKs billing office. I called them back to see what they wanted. His biller called to thank me for appealing my claim, she had received the letter a few weeks ago but had only been able to tell BK about it that day. He was very happy told her to call me to ask for a copy of the appeal I used so that it could be used for other patients with the same issue. I hope that it does and everyone who needs the surgery will be able to have it and move on with their life (some of us a little slower than others!!!)

The Exercises

2010-05-09T06:43:00.002-05:00

Once again I apologize for taking so long to post, my work schedule is horrendous, and I even had to go in on my day off this week, with the baby no less! I am tired, cranky and counting the days until this is over (Jun 14).

The exercises my PT gave me are not strengthening exercises, in fact, they are just stretching/ mobilizing exercises, and I am supposed to go back to him to get strengthening exercises. (My appointment is 3 weeks from now).

The exercises are meant to keep the anterior capsule stretched out and loose, I don't recommend you do them since most people don't have this problem of soft tissue impingement. The most simple one I do is sit in Indian style (yes, this is how I got into this mess to begin with!!) and put my hands behind me and hold the stretch (I try to hold for 60-90 seconds), if I don't feel enough of a stretch I do a posterior pelvic tilt.

I also do a mobilization with a mob belt, this requires another person. We wrap the belt around my thigh while they sit on a stool and the belt goes around them. Their job is merely to stabilize and provide a tiny bit of a lateral force. I keep my right (bad) leg behind me and stand in a position as if I was going to lunge. I put my arms out in front and rotate my body to the left, so my right leg is getting and external rotation force. This is a very specific an targeted mobilization for the anterior capsule. I am to do this 2x/week.

I can also do a half kneeling stretch but I have chosen not to, since I am getting great results for these 2.

My hip flexion has been as good as 115' degrees, pain free, it does tighten up if I slack off. I felt so great this week I did my first Pilates reformer class and (shhhhh) went Spinning on Fri. I have since tightened up a bit but I really needed that, I think I need to return to exercising as part of this final step in rehab/recovery. I have 2 more Pilates sessions planned for this week and really hope I can spin at least 3x/week for now.

I promise to keep you updated...but please be patient...I have never been so busy and overwhelmed in my life!

Problem Solved....Or So I Hope

2010-05-02T21:15:00.002-05:00

I know I am probably jumping the gun, but I definitely feel better mentally about what has been going on. I think I finally have an understanding of what the problem has been, and why I have been having so many issues and problems, and now the final fix will lie with me.

All along, it seems that my capsule has been too tight (since the last surgery), so, as it was explained to me for the millionth time (but this time I 'get it'), imagine that the capsule is like saran wrap, tightly covering the whole hip joint. If it fits well, it will keep the joint in place and allows it to move well through its range of motion. In very rare, super special cases, like mine, it gets too tight, so when I tried to flex my hip, there was no give in the "saran wrap" and it was getting bunched up in the front of the joint. That's why my flexion was so limited, and when I was having the "episodes" and all the clunking, it was the capsule snapping, or getting "unstuck".

The solution was to do some very specific mobilization, we had to tweak them on Friday, but I left PT on Fri so happy! I have had almost no catching/ clunking/ feeling of subluxation since then. I still have pain, but I have increased hip flexion too, so I am happy, and I think I need to be in a good place mentally at this point bc I have been close to losing it more than once.

I have specific stretches to do, to keep the capsule stretched, and twice per week I am supposed to have someone help we with a mobilization using a mob belt. It is an ER mob while my hip is stabilized in extension, it is amazing and works wonders.

I am supposed to begin strengthening in 2 weeks, I can't get back to PT for 4, so I may have to begin on my own. When I overdo the stretching, I can't walk well, and actually have a trendelenberg, bc my hip is not used to functioning in the new range.

I hope things go uphill from here, this is getting very very old!!

I apologize for not being on top of blogging, I am not really on top of anything lately, I have been working crazy hours and most things have fallen to the wayside...my MIL was here for the weekend and re-organized my closets bc they have gotten so messy!!!!

I Have Reached A New Low In Life

2010-04-29T21:45:00.002-05:00

Wednesday was my PT session, as I had discussed with BK and my PT at the conference we were at on Friday. The conference lasted 2 days but I was only able to attend the first one. When I arrived to PT on Wed, I told my PT that my friend who had attended both days loved his presentation on the second day. He asked if she had heard the part about the difficult case he has now, who has tightness anteriorly due to a tightened capsule, but laxity posteriorly due to a torn ligamentum teres....hmm, "is that me?" I asked....Yep!! So my all time low is that I am the "difficult" and "challenging" case that is spoken about at conferences.

So PT was good, he thinks that if he mobilizes me anteriorly, it will give me more space and less pinching. I pinch in the front at 90 degrees of flexion, which is very upsetting to me, I would like to have at least 120 degrees of painfree flexion.

He did his thing and I got about 100-110 degrees of painfree flexion. But I was a bit unstable because I was working in a new range that I was not used to. He did a few adjustments, I was sore but felt like we had made progress.

Once I got home I was having tremendous posterior pain, which made absolutely no sense at all. I guess this whole thing makes absolutely no sense at all...so I emailed my PT, who said to hold off on all stretches for now. I see him tomorrow for some more mobs. We spoke this morning again and I apologized for being so high maintenance!! He was going to speak to BK today and try to figure this whole thing out...again!

The Pow Wow

2010-04-25T06:20:00.002-05:00

Friday was the ortho conference given by HSS, the keynote speaker was Dr Byrd, which was very cool. Other speakers included BK and my PT. After the hip topic was over, Everyone swarmed over to BK, it was hysterical, he was so popular. He made his way through the crowd over to me, and we had a quick meeting! I said I just want us all to be on the same page about what is going on. So we agreed to try one thing in PT, he promised that if I wasn't getting good results he wouldn't make me do it for a long time, and that if when I am at PT this week, if things don't go well, he will come right over and see what is going on.
So, hopefully PT will be on Wed, and Wed night I will have great things to report!

And the Saga Continues...

2010-04-21T05:15:00.002-05:00

Have you ever felt like you needed a time-out from life? I think that is exactly what I need right now. I spoke with BK last night about my ultrasound, he said that, "just as he thought", the problem is that the capsule is thickened and impinging in the joint. He thinks that for now, the solution is anterior hip mobs to stretch it out a little bit and give it more space. This is rather conflicting since prior to the MRI and Ultrasound, my PT wanted to avoid anterior mobs since he felt the joint was a little bit unstable. Now the thought is that it is too tight. See why I need a time-out.
I was emailing back and forth with a fellow hip friend last night, and one of the things she asked is what do I think is going on? Honestly, I have no idea whatsoever, I usually have at least an idea, a thought, something... I am just plain confused now.
The plan is for BK to speak with my PT today and see if he agrees that this 'plan' is a good idea. We are all going to be at an ortho conference on Fri, so the plan is to have a quick little meeting there and discuss this all together.

At this point I don't know how much more of this I can take. I had a mini breakdown last night, because after 4 surgeries, 8 injections, months and months of PT....I am done...I don't want my hip to run my life anymore.

Ultrasound Report

2010-04-16T15:53:00.002-05:00

There is mild deep surface fraying of the iliopsoas tendon which is otherwise preserved. No associated iliopsoas bursa is evident. Of note, there is a focal capsular thickening corresponding to abnormality noted on MRI. Area of focal capsular thickening appears to immediately overlie the anterosuperior labrum resulting in mild mass impression on the labrum. No discrete snapping or pain could be elicited with provacative maneuvers.

Impression:
Mild ilipsoas tendinosis with deep sided fraying, right hip.
Focal lateral capsular thickening which appears to impinge along the anterosuperior labrum.

It was elected not to proceed with the ultrasound guided injection today pending discussion with referring clinician.

Sometimes Even I Can't Believe that These Things Happen To Me

2010-04-14T20:19:00.002-05:00

Today was supposed to be my ultrasound with 'possible' injection, based on what the radiologist and BK saw on the ultrasound. All was going well, I arrived to the hospital on time, they actually did have the appointment scheduled (which I am always a little shocked at!). Then things started going downhill, and all I can say is that I was fucking pissed.

The radiologist came in and looked at the prescription and chuckled a little, "possible injection?" he asked, so I explained that BK was supposed to be there too, so his assistant called BKs office, who, let me sidetrack for a moment, knew that this was supposed to be scheduled so that he could come, as well as my PT, since I had first told the scheduler and then he did as well. Well, you can imagine my shock when the radiologists assistant reported back to us that BK was on vacation. NFW. Why the hell was this scheduled for today then???? So, as you can see, this is why I am not just pissed, I am fucking pissed.

So the radiologist did the ultrasound, wasn't too interested in hearing what I had to say, or have me explain what exactly happens, and that I can't reproduce it at will. He did say that my psoas is somewhat irregular and the capsule is very thick. I asked if it was thick bc of the capsular shift, he said it was even too thick for that. He said he could inject either the psoas or the capsule or both, but really needed to know what BK wanted. So no injection today.

I left rather pissed off, but treated myself to some retail therapy!

UHC: 0 Susie: 1

2010-04-09T05:40:00.003-05:00

I just checked my online EOBs with UHC and my surgery has been PAID for!! Whoohoo!!! They are paying $6750. I have not received anything in the mail yet, like a letter, an explanation, an apology :-) but just decided to have a look online!!!! What a way to start to the weekend!!

Stepping on Glass Was One of The Best Things I Could Have Done

2010-04-08T21:14:00.002-05:00

I apologize for going MIA while in MIA! Things were just really hectic and I found it difficult to get to the computer.
My trip began with Z having a horrific diaper rash. As a remedy, I was letting him run around without a diaper. He ran into a corner and decided to poop on the floor. As I went to get him he knocked over a crystal picture frame and it shattered. There was glass everywhere and I just so happened to step on it and cut my foot...badly. So for 2 days I was pretty much homebound since it hurt to walk on my foot. My hip felt great with this rest! The rest of this trip was pretty low key, and as usual, Miami was a great 'cure' for hip pain!

I am beginning to think that the 'episodes' I was having were indeed my psoas doing something funky, but I still am not sure what exactly it is doing. I think that when I flex and feel whatever it is I feel, it is the psoas. I dont know what it is doing or why, or what the solution is, but I don't know if it is subluxing. I guess I am just confused again!

My ultrasound is next week, so hopefully it will shed some light on the matter!

Now Its Tight...

2010-03-24T07:17:00.002-05:00

Beginning this week, I have changed my work schedule. I used to work three 5 hour days, 15 hours per week. For the next 3 months, I am working three 12 hour days....I know, a huge change! I have been really concerned about how my hip would hold up. So far it hasn't been too bad. Yesterday it started feeling really tight. My psoas started snapping even more than usual and I was unable to take large steps with my left leg bc the right couldn't go too far into extension. It was so strange, all the muscles just decided that they had had enough with this instability crap and kicked into high gear to protect my hip from sliding around. I hate this tight feeling but I also hate the instability........

Timeline Recap

2010-03-21T20:32:00.002-05:00

If you have just begun to read my blog now, it may seem confusing, and you may not know how I got to where I am, and how a 29 year old, otherwise healthy person, can have so many issues with one joint! Here is a link to my "timeline", which when I remember, I update!

Hip MRI #5

2010-03-21T11:00:00.004-05:00

Patient is status post debridement of the femoral head enck junction with reconstruction of an anatomical offset. The anterior labrum has been debrided and is diminutive but without tear.
There is irregularity of the anterior joint capsule best appreciated on the oblique axial images, more prominent than previous, perhaps representing the recent anterior surgical approach.

Superior labrum has been debrided since previous and is now deficient. Posterior labrum shows a prominent sublabral foramen, unchnaged from previous.

Sagittal images show irregularity of the cartilage of the anterior aspects of both the acetabulum and femoral head, not significantly changed. There is generalized thinning of cartilage over the anterior aspect of the femoral head best appreciated on the oblique axial images, but also unchanged.

Superior aspect of the acetabular cartilage is preserved. Cartilage over the posterior aspect of the acetabulum is thinned.

Small joint effusion is present.

Negative for greater trochanteric or iliopsoas bursitis.

Signal from bone is normal. The sacroiliac joints are preserved. At L5-S1 there is a focal midline disc protrusion causing mild-moderate central stenosis, unchanged from previous.

Signal from pelvic musculature is normal. There is very mild degeneration of the hamstring origins.

Right hip shows approximately 6 degrees of corrected femoral retroversion. Left hip shows approximately 8 degrees of corrected femoral anteversion.

Impression:
Superior labrum has been debrided since the previous examination. Cartilage wear over the acetabulum and femoral head is unchanged. The increased prominence of the anterior capsular defect most likely represents the recent surgery.

An Answer???? I Think Not!

2010-03-21T07:00:00.002-05:00

So I did get a reply to my email which is still not helping me really understand what is happening! There may be "soft tissue(capsule/psoas/scar) pinching in the front of the joint with flexion. Whether it is the psoas getting stuck, or just capsular thickening, or scar, I don't know, that is what I hope to see with the ultrasound".
My problem with all of this is that my psoas snaps, always has...but in extension, not flexion. I don't seem to 'get' what is happening in flexion. Of course it didn't do it while I was there, and I can't reproduce it at will! I haven't had a huge, standing subluxation in almost 2 weeks, which is a good sign, just the sitting one this past week.

My other question was about my increased ER, which is quite excessive. His response was that I have so much ER probably due to the improved offset superolaterally, as seen on my most recent MRI.

So still no concrete answers, which is why I am having such a hard time with this.

The Appointment

2010-03-19T15:39:00.001-05:00

I'm not sure how to describe today's appointment. I went with J for moral support because I have been having a hard time dealing with my continued hip issues. Before coming in to see me, BK looked at my MRI and from what I could hear through the door, he was confused by what he saw. He had to call the radiologist to go over it with him.
When he came in to see me, he did some moving of my hip and it clicked, he said that was psoas. I have no pain in ER which again, he found strange. My "secret" PT joined us so we were all able to discuss the situation. BK thinks that based on my MRI, I am having a problem with my psoas. It is getting caught in the joint, this is why I have so much pain, the psoas is inflamed. The reason I have posterior pain is because of the way I am sitting to avoid pinching the psoas. He doesn't think the joint is shifting or subluxing...I don't know if I agree or if I even understand everything he said.
He wants me to get a dynamic ultrasound so he can see exactly what is happening. He would like to try to be there for it, as well as my PT. This should be interesting to schedule!
When we left, I was visibly upset. J wanted to know what was wrong, he thought it had gone very well! I don't know what I thought but I was very confused and didn't seem to understand everything. I still feel like I am missing something...I think we all are. I ended up emailing BK about it and explained that I am confused and asked if he could go over it again with me. I hope I hear back soon!

Valium.....Ahhhh

2010-03-17T21:16:00.002-05:00

Ok, what the heck was I thinking for the past 4 MRIs....MRIs with Valium are the equivalent of getting a massage...and having your insurance foot the bill!! I have never actually enjoyed an MRI...until today. I was sorry it was over because I was so relaxed and happy. It flew by! I didn't want to get up when it was done! I could kick myself for not having requested it the other times...Oh well, live and learn!!!

Got Confirmation Yesterday

2010-03-16T05:30:00.002-05:00

I got a letter saying that UHC has received my appeal and do I or anyone else want to add something. This gives me the perfect opportunity to send the new policy over to them. Anyone else have anything to add??? I know we all have something we want to say to them but I think I should watch my language in these letters!!

How Akward Is This

2010-03-10T06:47:00.002-05:00

Yesterday, my good friend C called and told me that she had hurt her back, and was wondering if I could help her, and if I wanted to go to Target. Of course I said yes (to both). Around 7:00 she called to see if I was ready to go, I was, just had to change...until I went to pick something off of the floor and boom- my hip subluxed and totally threw my a curve ball. It hasn't subluxed "that much" since I have been more aware of the problem. I have been really careful and usually, once I feel the tiniest amount of sliding, I somehow manage to guard and not allow ti to sublux. Last night I couldn't. Within minutes, I was in a ton of pain. I called C back and had to explain why I could no longer fix her back or go to Target: "Ummm...I need to re-schedule, my hip kinda dislocated and it hurts a lot now...can you do tomorrow?" I think I should start taking my MRI Valium NOW!

Instability Is The New "Black"...

2010-03-08T20:22:00.002-05:00

...Or at least the new "mystery" diagnosis that is being studied, kind of like FAI used to be, according to my OS. So once again, I am just a mystery...he has never seen anyone quite like me before. I am going to get an MRI hopefully this week and hopefully he can get an idea of what is going on. I am getting Valium for this one!!!

UHC- Revised Policy- Great News For Hipsters!!!

2010-03-08T15:30:00.002-05:00

Surgical treatment, both arthroscopic and open, for femoroacetabular impingement (FAI)syndrome is proven*.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Femoroacetabular_Impingement_Syndrome.pdf

Great news for all of us with UHC!! Thank you to everyone who wrote letters, appeals, made phone calls and was interviewed. What an accomplishment!

In An Unrelated Story...

2010-03-07T17:56:00.001-05:00

This week marked the 3 year anniversary of my left hip arthroscopy. Things have been great with Left, one surgery for a labral tear, cam and pincer FAI, 12 weeks of PT and done!!! Right hip....take a lesson!!

And The Nightmare Continues...

2010-03-07T11:01:00.000-05:00

I got a response to the email I sent to my OS. He was at a meeting with my PT and they were discussing my unfortunate turn of events. He first wants me to get an MRI...this will be my 5th MRI in 3 years...did I mention I am claustrophobic??
All I keep thinking is that this is not going the way I had hoped...at 14 weeks post op, I am not supposed to be having MRI's, or depressing email conversations with my OS...what went wrong???? Why is this happenning????

Article on Capsular Laxity

2010-03-05T09:33:00.002-05:00

Thank you to the generous people at JBJS for providing free articles to patients. I have a full copy saved on my desktop, if you would like it, email me suzq613@aol.com

Anterior Dislocation of the Hip After Arthroscopy in a Patient with Capsular Laxity of the Hip
A Case Report
Anil S. Ranawat, MD1, Michael McClincy, BA2 and Jon K. Sekiya, MD3
1 Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address: ranawatanil@hss.edu
2 University of Pittsburgh School of Medicine, 567 South Negley Avenue, Pittsburgh, PA 15232
3 Department of Orthopaedic Surgery, MedSport – University of Michigan, 24 Frank Lloyd Wright Drive, P.O. Box 0391, Ann Arbor, MI 48106. E-mail address: sekiya@umich.edu

Investigation performed at the University of Pittsburgh, Pittsburgh, Pennsylvania

The first 150 words of the full text of this article appear below.

Introduction

Capsular laxity is a poorly understood but increasingly recognized cause of hip pain1,2. As with shoulder instability, hip instability represents a wide spectrum of pathologic entities, ranging from acute traumatic dislocation to chronic capsular laxity. Primary capsular laxity is often associated with underlying collagen abnormalities, such as those seen with Ehlers-Danlos or Marfan syndrome. Secondary capsular laxity is seen more commonly in athletes and is secondary to overuse or repetitive activities2.

Although the mainstay of treatment for these conditions has been nonoperative, surgical intervention may be indicated because of either recurrent instability or lack of pain relief with nonoperative measures. Surgical treatment may require access to both the hip capsule and the labrum through either an open3-5 or an arthroscopic6-12 approach. Although the latter techniques are relatively new, two studies have demonstrated that arthroscopic surgery can provide stability to the hip joint10,11. However, while arthroscopic techniques are . . .

UHC Contacts

2010-03-05T06:54:00.003-05:00

As I sit, wondering what will be with my appeal, I came across this website with some UHC contacts with email addresses. Since so many of you are finding my blog by googling terms like "UHC FAI" or similar things, especially in regards to denials, I thought this may be helpful.
IN the event that you do need to use these, keep in mind that it wasn't until I sent 2 emails to their VP of PR that someone responded to me.

http://consumerist.com/2008/03/email-addresses-for-united-health-care-executives.html
Read the comments, I found them interesting!

My Appeal Letter To UHC To Cover My FAI Surgery

2010-03-03T23:05:00.002-05:00

TO: UnitedHealthcare Appeals Department

DATE: February 29, 2010

FROM: Name
Member #
Claim #:

RE: Appeal Letter Regarding Arthroscopic Hip Surgery

Mailed to _______________________

Dear Sir/Madam:

This letter serves as an appeal to the UHC denial of the arthroscopic hip surgery performed by Dr. ____on 11/30/2009. This surgery was performed to debride a torn acetabular labrum as well as to correct my femoroacetabular impingement (FAI) syndrome. United Healthcare’s rationale is that arthroscopic surgery for FAI is unproven; this was documented in a letter dated 12/30/09 from Bradley J. Osborne, MD, Medical Director. This letter states that these services are “experimental or investigational”.

United Healthcare’s decision should be reversed for three reasons. First, I have undergone this procedure by the same in-network physician in the past, and it has been covered by UHC (3/5/07, 7/2/07 and 11/12/07). Second, my medical history demonstrates that a surgical alternative was necessary and appropriate. Third, the medical literature and coverage by other major insurers supports the use of arthroscopic surgery for FAI, therefore, it would appear to the reasonable person that UHC is discriminatory in their policies.

I. This Procedure Has Been Covered In The Past

I have undergone this procedure 3 different times in the past, the first one was performed on March 5, 2007, the second was performed on July 2, 2007 and the third was performed on November 12, 2007. These procedures were covered at the negotiated rate with UHC, as Dr ____ is an in-network provider. I was never notified by UHC that this procedure would not be covered. Obviously, my concern is the reliability of UHC. There must be consistency of processes in order to avoid costly mistakes like this

II. My Medical History Supports A Surgical Response

Femoroacetabular impingement (FAI) occurs when the ball (head of the femur) does not have its full range of motion within the socket. It is the main cause of early damage to the acetabular labrum and articular cartilage of the hip, particularly in young, active patients and high level athletes. Impingement causes pain, decreased range of motion and mechanical symptoms such as locking of the joint.

I relentlessly attempted to manage my FAI with conservative measures, including strengthening of the hip muscles, activity modification and several injections into my hip; however, my pain became debilitating and my range of motion became quite limited. As a young, active, and very healthy 29 year old, and only after conservative treatment failed, I decided it was best to pursue surgical treatment because chronic pain and immobility can lead to risk for multiple health conditions, such as obesity, depression, diabetes not to mention the very realistic probability of needing a premature total hip replacement.

My doctor, Dr.____– a world renowned expert in arthroscopic hip surgery –explained that I had exhausted all of my conservative options and in order to relieve my symptoms, he recommended arthroscopic hip surgery because it involves minimal complications, minimal pain, very low risk of infection, and a short recovery time, all on an outpatient basis. There are other treatment options that include open surgical dislocation as well as a total hip arthroplasty, but unlike arthroscopic treatment, these require that the hip be dislocated which increases the risk of avascular necrosis. As you are aware, avascular necrosis by itself is a complication that can contribute to serious morbidity. Thus, the risks and the potential costs to United Healthcare and the patient, are lower with the arthroscopic procedure. This is also confirmed by the Hayes report as the clinical options. Additionally, at my current age, activity level, and amount of cartilage wear, I do not qualify for a total hip replacement.

Please note that I am well on my way to an excellent outcome thanks to Dr.____’s ability to provide me the state-of-the-art treatment that has been developed and tested, as evidenced by scholarly publications and as an approved surgery by Blue Cross, Kaiser, Blue Shield, Cigna and other insurance companies. This surgery has improved my quality of life and ability to function, which will allow me to avoid premature total hip arthroplasty and the medical treatments associated with chronic disease.

III. The Medical Literature Supports this Procedure for FAI

As indicated in the outset of this document, United Healthcare has denied coverage because this procedure is “unproven.”

United Healthcare’s definition of “unproven services” is as follows:

“Services that are not consistent with conclusions of prevailing medical research which demonstrates that the health service has a beneficial effect on health outcomes and that are not based on trials that meet either of the following designs.
-Well conducted randomized controlled trials
-Well conducted cohort studies
Decisions about whether to cover new technologies, procedures and treatments will be consistent with conclusions of prevailing medical research, based on well-conducted randomized trials or cohort studies, as described.”

A review of the “prevailing published peer-reviewed literature” shows that arthroscopic surgery is not “unproven” for FAI.

In regards to my condition and the treatment Dr. ___provided, UHC should fully understand that FAI is a condition that is painful and debilitating as was my experience as well as countless others. As Dr. Osborne, the original UHC denying doctor, is a general surgeon he may not know the extent of the disability associated with FAI. It is a condition that has been recognized in the literature since the 1930’s (Smith & Peterson, 1936). Femoroacetabular impingement syndrome is the result of abnormal contact between the proximal femur and acetabulum and can result in intra-articular pathology and eventual osteoarthritis (Beck et al., 2004; Ganz et al., 2003).

Furthermore, FAI is one of the most common causes of premature osteoarthritis in men and women (e.g., Ganz et al.., 2003; Murray & Duncan, 1971; Smith & Peterson, 1936).

Although the open hip procedure has historically been the “gold standard,” perhaps due to previous technological limitations, there are extensive complications, chronic disability and pain associated with it as well. Additionally, UHC has recently taken the position to not cover open FAI surgery. Again, UHC is being discriminatory in their coverage for FAI. UHC has refused to pay for ANY required surgical repair of this syndrome.

Bedi et al. (2008) published a systematic review of the surgical treatment of FAI syndrome. These authors report that there are only five scholarly articles (peer reviewed journals) published reporting outcomes of the open surgical approach with 20 or more hips included. Good outcomes achieved ranged from 65-85% of hips (Beck et al., 2004; Beaulé et al., 2007; Espinosa et al., 2006; Murphy et al., 2004; Peters & Erickson, 2004).

There are more outcome studies published in peer-reviewed journals on the arthroscopic correction of FAI syndrome and/or other intra-articular pathology that include 20 or more hips, which is a stronger compilation of evidence than for that of the open procedure (Byrd & Jones, 2000; Farjo et al., 1999; Ilizaliturri et al., 2008; Larson & Giveans; O’Leary et al., 2001; Philippon et al, 2007; Potter et al., 2005; Santori & Villar, 2000).

Of high importance, the success rates of the arthroscopic procedure were achieved without the complications, such as avascular necrosis, associated with the open hip dislocation. In fact, the Hayes report indicates that there is a 1.3% complication rate with the arthroscopic procedure compared to a “10-12%” complication rate of the open hip surgery. Additionally, more recent studies not included in the Bedi et al. article, support evidence for long-term benefits (Ilizaliturri et al., 2008; Philippon et al., 2009).

Although the Hayes report provided a superficial analysis of the evidence for United Healthcare, there is one thing in the Hayes report that clearly stood out: arthroscopic FAI surgery must be performed by an orthopedist with special training in hip arthroscopy. Not only does Dr. ___have special training, he is an international leading expert in arthroscopic hip surgery, which is partially reflected by prestigious publications in multiple peer reviewed journals.

United Healthcare seems to believe that arthroscopy is unproven because studies only cover a two-year period as indicated in “Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up.” Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. J Bone Joint Surg Br. 2009 Jan;91(1):16-23. My question for United Healthcare is would four years be enough? Ten years? This seems like nothing more than a convenient excuse to avoid coverage of a procedure that has proven to be safe and effective.

In a more recent article published by Byrd and Jones, “Prospective Analysis of Hip Arthroscopy with 10-year Followup”, response to hip arthroscopy was investigated in a consecutive series of patients with 10 years followup. All patients undergoing hip arthroscopy were assessed prospectively with a modified Harris hip score preoperatively and then postoperatively at 3, 12, 24, 60, and 120 months. The median improvement was 25 points (preoperative, 56 points; postoperative, 81 points). This study substantiates the long-term effectiveness of arthroscopy in the hip as treatment for various disorders, including labral pathology, chondral damage, synovitis, and loose bodies.

There are many published studies indicating the effective results of arthroscopic treatment of FAI. The largest study to date is Sampson, T.G. (2006) “Arthroscopic treatment of femoraoacetabular impingement; a proposed technique with clinical experience.” In this study of 183 hips, 94% achieved a high degree of satisfaction with the surgical outcome. Only six patients had subsequent total hip arthroplasties. The results further showed that for the majority of patients’ pain decreased by 50% in 2 to 6 weeks, 75% by 5 months, and 95% by 1 year. In addition, there has recently been a publication in the British Journal of Bone and Joint Surgery by Dr. Marc Philippon. He is an authority on the subject and has published extensively on the topic, as you should be aware. In this article he documents the improvement provided to a group of patients undergoing the arthroscopic procedure with over two years of follow-up. The reference for the article is: “Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up.” Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. J Bone Joint Surg Br. 2009 Jan;91(1):16-23.

Again, United Healthcare relied on a Hayes report that UHC says was updated based on studies from 2007 and 2008. However, the key study by Philippon from 2009 was not utilized in UHC’s “science” based determination of my claim. Additionally, the small print in the Hayes report indicates that this report “is not intended to be used as the sole basis for determining coverage, reimbursement or technology acquisition” (Hayes report). There was no indication that my clinical information or communication initiated by UHC with my physician was taken into account.

United Healthcare claims that there may be (not are) problems in the long term. United Healthcare can cite no study showing that there are problems in the long term. In fact, there is no evidence of this, and what we do know is that this procedure avoids avascular necrosis, the risk of which is inherent in an open procedure. So what has to be balanced is the risk of avascular necrosis and other serious complications against the entirely speculative possibility of long-term problems with arthroscopic surgery. In other words, we are balancing a known complication against an unknown, entirely speculative one.

The circumstances in which this surgery was performed, and the literature pertaining to this surgery, have not yet been reviewed by an orthopedist. United Healthcare’s reviews have been by a general surgeon. I strongly believe that, if a proper review was conducted, the finding would be that this procedure ought to be covered as it is covered by Kaiser, Blue Cross, Blue Shield, Cigna and others.

In conclusion, it appears that UHC needs to catch up with the evidence, and reverse their policy of viewing arthroscopic, as well as open treatment of FAI as unproven. Not only is this false, as evidenced above, it is discriminatory to those afflicted with the condition. Specifically, denying the procedure to patients is clinically wrong and misguided. There is clear literature to support the lasting improvement afforded by this operation. More importantly, not performing the procedure and letting patients wait until they are in enough pain or have enough deformity to warrant a total hip replacement keeps patients in pain and suffering for an inordinate amount of time. There is a procedure that can help patients and improve their quality of life with a minimum of surgical trauma, yet you choose to disallow it, based on a superficial analysis of the available clinical series.

IV. Conclusion

Despite my good physical recovery, I have been unnecessarily stressed by the lack of a fair and consistent policy UHC has demonstrated since my claim was filed. Be assured that I intend to use every available means to get this matter resolved as I’m interpreting UHC’s actions to be discriminatory. In the meantime, I will await a thorough and scientific review of my appeal by an orthopedic specialist apprised of the current knowledge base surrounding FAI. I am expecting payment on my claim as I believe the literature does support that this procedure is not unproven. This is also evidenced by multiple other insurers covering this procedure.

Please do not hesitate to contact me with any specific questions or if additional information is needed.

Sincerely,

Susie

Additional References

Prospective Analysis of Hip Arthroscopy with 10-year Followup. Byrd JW, Jones KS. Clinical Orthopaedics and Related Research

Sports and Recreation Activity of Patients With Femoroacetabular Impingement Before and After Arthroscopic Osteoplasty. Brunner A, Horisberger M, Herzog RF.
Am J Sports Med. 2009 Feb 26. [Epub ahead of print]

How accurately can the acetabular rim be trimmed in hip arthroscopy for pincer-type femoral acetabular impingement: a cadaveric investigation. Zumstein M, Hahn F, Sukthankar A, Sussmann PS, Dora C.
Arthroscopy. 2009 Feb;25(2):164-8.

Arthroscopically assisted anterior decompression for femoroacetabular impingement: technique and early clinical results.Hartmann A, Günther KP. Arch Orthop Trauma Surg. 2009 Jan 6. [Epub ahead of print]

Arthroscopic femoroplasty in the management of cam-type femoroacetabular impingement. Byrd JW, Jones KS. Clin Orthop Relat Res. 2009 Mar;467(3):739-46.

Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up. Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. J Bone Joint Surg Br. 2009 Jan;91(1):16-23.

Femoroacetabular impingement treatment using arthroscopy and anterior approach.
Laude F, Sariali E, Nogier A. Clin Orthop Relat Res. 2009 Mar;467(3):747-52.

Arthroscopic management of femoroacetabular impingement: early outcomes measures.
Larson CM, Giveans MR. Arthroscopy. 2008 May;24(5):540-6.

Complications of arthroscopic femoroacetabular impingement treatment: a review.
Ilizaliturri VM Jr. Clin Orthop Relat Res. 2009 Mar;467(3):760-8.

Arthroscopic treatment of cam-type femoroacetabular impingement: preliminary report at 2 years minimum follow-up.Ilizaliturri VM Jr, Orozco-Rodriguez L, Acosta-Rodríguez E, Camacho-Galindo J. J Arthroplasty. 2008 Feb;23(2):226-34.

Arthroscopic treatment of femoroacetabular impingement secondary to paediatric hip disorders. Ilizaliturri VM Jr, Nossa-Barrera JM, Acosta-Rodriguez E, Camacho-Galindo J. J Bone Joint Surg Br. 2007 Aug;89(8):1025-30.

Early outcome of hip arthroscopy for femoroacetabular impingement: the role of femoral osteoplasty in symptomatic improvement. Bardakos NV, Vasconcelos JC, Villar RN.
J Bone Joint Surg Br. 2008 Dec;90(12):1570-5.

Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: a preliminary report. Philippon MJ, Yen YM, Briggs KK, Kuppersmith DA, Maxwell RB. J Pediatr Orthop. 2008 Oct-Nov;28(7):705-10.

Treatment of femoro-acetabular impingement with surgical dislocation and débridement in young adults. Peters CL, Erickson JA. J Bone Joint Surg Am. 2006 Aug;88(8):1735-41.

Arthroscopic offset restoration in femoroacetabular cam impingement: accuracy and early clinical outcome. Stähelin L, Stähelin T, Jolles BM, Herzog RF.
Arthroscopy. 2008 Jan;24(1):51-57.

Influence of femoroacetabular impingement on results of hip arthroscopy in patients with early osteoarthritis. Kim KC, Hwang DS, Lee CH, Kwon ST.
Clin Orthop Relat Res. 2007 Mar;456:128-32.

Quality of life following femoral head-neck osteochondroplasty for femoroacetabular impingement. Beaulé PE, Le Duff MJ, Zaragoza E.
J Bone Joint Surg Am. 2007 Apr;89(4):773-9.

Femoroacetabular impingement in 45 professional athletes: associated pathologies and return to sport following arthroscopic decompression. Philippon M, Schenker M, Briggs K, Kuppersmith D.
Knee Surg Sports Traumatol Arthrosc. 2007 Jul;15(7):908-14.

Debridement of the adult hip for femoroacetabular impingement: indications and preliminary clinical results. Murphy S, Tannast M, Kim YJ, Buly R, Millis MB.
Clin Orthop Relat Res. 2004 Dec;(429):178-81.

Hip damage occurs at the zone of femoroacetabular impingement.
Tannast M, Goricki D, Beck M, Murphy SB, Siebenrock KA. Clin Orthop Relat Res. 2008 Feb;466(2):273-80.

Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Clin Orthop Relat Res. 2004 Jan;(418):67-73.

Revision hip arthroscopy. Philippon MJ, Schenker ML, Briggs KK, Kuppersmith DA, Maxwell RB, Stubbs AJ. Am J Sports Med. 2007 Nov;35(11):1918-21.

Attachment 1

Examples of Other Insurance Carriers Policy on FAI Including:

Cigna

BlueCross BlueShield of North Carolina

BlueCross BlueShield of Mississippi

Regence

Anthem

(I printed out the above companies policies and included them)
BCBS N. Carolina: http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/arthroscopic_surgery_for_femoroacetabular_impingement.pdf
BCBS Mississipi:
http://www.bcbsms.com/index.php?q=provider-medical-policy-search.html&action=viewPolicy&path=/policy/emed/Surgical%20Treatment%20of%20Femoroacetabular%20Impingement.html
Cigna:
http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0485_hip_arthroscopy_for_femoroacetabular_impingement_syndrome.pdf
Anthem Blue Cross
http://www.anthem.com/medicalpolicies/policies/mp_pw_b099013.htm
Kaiser demonstrates their surgery for FAI:
http://xnet.kp.org/misg/procedures/orthopedic.html
Regence covers it as well.

Attachment 2

Copy of an external review for another UHC member who was denied coverage for an almost identical procedure. Please note that this reviewer, an orthopaedic specialist, stated that this procedure should not be considered investigational or experimental at this time. Additionally, this external reviewer indicated that UHC was arbitrary and unethical in their decision to deny this claim.

Good News and Bad News

2010-03-03T18:29:00.001-05:00

This is what I told J I had for him when I left PT today. He wanted to hear the bad news first.

Bad News: my hip is pretty f--ked up. My PT has never seen anyone with my issue, meaning someone who has so much instability following a capsule repair. He is not really sure what to do but is not giving up. In the meantime, he gave me one simple exercise to do at home. I see BK in 2 1/2 weeks so until then, this is it. My pain has been excruciating at times. Yesterday I had a 2 hour meeting and thought I was going to die when I left. This is just like pre-op, when I go to work I have pain. I am going to email BK tonight to see if he has any thoughts.

Good News: I had no co-pay at PT because he felt so bad for me!

More UHC.....

2010-02-25T18:32:00.000-05:00

As I have noted in the past, UHC has denied payment for my last surgery. It has been resubmitted numerous times and still denied. After Maria's article was published, I contacted Cheryl Randolph, the PR exec from UHC quoted in the article via email, regarding my claim. I cc'd a few other PR people at UHC as well. I got no response. I sent another email to the same group of people this week, but signed it with my credentials (thanks Maria!). When I got home from work today I had a message from Linda @ UHC regarding my emails.

I called the number and got UHC corporate offices...ooh lala! Linda is a consumer advocate, she told me I would need to appeal the decision. What I explained was that I didn't see the need to do this since the procedure had already been paid for 3 previous times. She was stumped. Regardless, she said to write an appeal and send it to her, and she would expedite it and get it to the right people. And to make sure I stated that it had been previosuly paid for.

I don't know if in the end this will help me or not, but it pays to be the squeaky wheel...someone is going to listen...or get really annoyed!

FML

2010-02-24T20:20:00.002-05:00

That pretty much describes the way I am feeling right now. I am having a lot of discomfort in my joint, and have felt my hip "shift" or "sublux" or "de-stabilize" or something multiple times. I am not a happy camper to say the least. I had PT today and my therapist is very concerned about this. He thinks that my femoral head is sitting anterior, which is why I don't have full hip flexion, and why I am so unstable. It is anterior because I have nothing restraining it, I ruptured the ligamentum teres on that 'fateful' June night, and he is pretty sure that my capsular shift was ineffective. He thinks that most likely my capsular tissue was no longer of good quality and just couldn't hold the repair.

That leaves me beyond upset, angry, sad, disappointed.....3 fucking surgeries later and I still have pain. He told me not to give up yet....he is not giving up yet. At this time I am really inflamed so I can't do much of anything. He was also palpating around my ASIS/AIIS and found swelling...he is not sure why but thinks that something there is also very inflamed and irritated. Fabulous.

I am to do one exercise for now. Lying on my back with my knees bent, push my hands into my knees and hold for about 10 seconds. This is to activate my abs...which have most definitely shut down. I iced with the gameready afterwards...it felt great. He wants me to rent one for now but I know I won't use it! It is bags of frozen vegetables for me!!!

He also thinks it may be helpful to get an active fluoroscopy of me bending forward to see exactly what is happening in the joint, and to get an idea of how 'fixable' I am!

Back To Work!

2010-02-23T18:18:00.002-05:00

Well, the party had to end at some point I guess, and it was back to work for me yesterday! Work itself went well, it was extremely busy and I had a ton of paperwork, but I managed! Yesterday morning I had what I have come to call one of my "episodes", where I will be doing something and my hip feels like it is subluxing. It usually happens when I am bending down to get something from the floor. It really hurts and is really disconcerting, especially after having surgery to stabilize my hip. I had on and off pain throughout the day, at periods I had no pain at all and others I had excruciating pain. Today was the same, on and off pain throughout the day.I am extremely frustrated with this and was hoping that by 3 months I would be past this. Tomorrow I have PT so hopefully we can work on stabilizing me a little bit and avoid this.

Good News For One Reader

2010-02-22T19:15:00.002-05:00

Whenever someone posts a comment on my blog, I get an email about it, even if it is an old post. I was thrilled to get this comment today from Tim on the post about UHC's new FAI ruling:

"I just had my 2nd level appeal hearing with UHC today. Great news! They called back within 15 minutes and have agreed to pay for the surgery I had last September"

Congratulations Tim!!! I hope to get more news like this very soon from many readers!!!

Overcoverage, Undercoverage...Why Can't I Just Get It Right!

2010-02-17T23:36:00.000-05:00

I have been totally slacking on the blogging front and once again apologize. I just feel the need to be done with hip shit once and for all.
I am totally done with my original PT and now on to PT #2, who works closely with my OS.

I have been having some feelings of instability, especially when I bend down quickly. Also, I went sledding on Sunday and walking up the hill killed me the next day. I had a lot of groin pain and got really nervous.

I told PT #2 that I really want my full hip flexion, on top of the other things that are going on. He said that one of the issues is that my capsular shift is not doing what its supposed to do, and my hip feels "sloppy", when he externally rotates it there is almost no end feel, it just flops. He also felt that my femoral head was too anterior causing it to jam up into the joint, so he wants to try some things to reposition it. He ended up taping me into a little pelvic anterior rotation to try to get more coverage of the femoral head. After a few hours I had a lot of back pain so had to remove it. We are going to work on some exercises from now on to get that back into place.

He also worked on some muscles trying to get my hip flexion increased. There is a spot on the inside of my leg where the adductor meet the VMO that is incredibly tender, he worked it so hard but it increased my ROM...not without leaving behind some nasty marks though!

I go back to work on Monday...I am nervous about it...I will keep you posted!

Take That UHC

2010-02-07T07:10:00.003-05:00

Many many thanks to fellow hipster Maria, who is paving the way for the rest of us to have our claims paid. Below is an article she was interviewed for in the New York Times. As you can see, the article quotes Cheryl Radolph, VP of PR at UHC, who says "the company is now rethinking things once again because of "the changing landscape of medical literature" about the procedure"

Funny, because my surgery was not covered, and the reason UHC gave me is that "This Service Is Unproven And Is Not Covered. Therefore, No Benefits Are Payable For This Expense. In Order For This Service To Be Considered For Coverage, Scientific Evidence Must Be Submitted, That Meets The Standards Described In Your Benefit Plan Language, That Demonstrates The Safety And Effectiveness Of This Service For Your Particular Condition".

Fighting Denied Claims Requires Perseverance

MARIA CARR, a 43-year-old school administrator from Tulare, Calif., could not believe it when her insurer, UnitedHealth, denied coverage for arthroscopic surgery she underwent last year to treat a bone spur on her hip.

Her doctor told Ms. Carr he had successfully performed this procedure for eight other UnitedHealth patients suffering from the same ailment in the same year. To Ms. Carr’s mind, arthroscopy seemed a much less invasive and cheaper way to treat the problem than open hip surgery, the traditional treatment for bone spurs.

“When the denial came I was shocked,” Ms. Carr said, “but I figured I’d just have to find a way to pay.” The total bill for the hospital and surgeon fee was $21,225.

Ms. Carr’s form of shock is all too common. The Department of Labor estimates that each year about 1.4 billion claims are filed with the employer-based health plans the department oversees.

Of those, according to data collected from health insurance industry sources, 100 million are initially denied. In simpler numbers, that is one of every 14 claims.

But Ms. Carr, whose hip pain ceased after the arthroscopic surgery, did not give up on the reimbursement. And neither should you. When Ms. Carr, a special education administrator at a local charter school, read her explanation of benefits statement more carefully, she spotted some instructions on how patients can appeal denied claims.

“I decided I would fight,” she said. “After all, what did I have to lose?”

Ms. Carr researched medical journals and other publications to find proof that her procedure was a bona fide and safe treatment. She then wrote a formal letter to her insurer making her case and including copies of the research she had found. Her doctor backed her up with a thorough letter of his own.

The appeal was initially denied, but Ms. Carr kept fighting. She took her case to her insurer’s external review board, where an impartial medical expert weighed the evidence.

The expert agreed with Ms. Carr, saying UnitedHealth had to pay the claim. “The expert felt UnitedHealth couldn’t call the procedure experimental if it paid for other patients to have it,” Ms. Carr said.

UnitedHealth ended up paying $12,282 for Ms. Carr’s claim — at a rate the insurer negotiated with the doctor and hospital. Ms. Carr’s share was about $500.

“That’s what the appeals process is there for,” said Cheryl Randolph, a spokeswoman for the insurer. “We’re glad it worked for her, and we encourage members to exercise their right to appeal whenever they need to.”

Not that UnitedHealth now happily pays all such claims. Soon after Ms. Carr’s successful appeal, the insurer revised its policy to stipulate that it did not cover that type of hip procedure — although Ms. Randolph says the company is now rethinking things once again because of "the changing landscape of medical literature" about the procedure.

Whatever the treatment or procedure a patient receives or is contemplating, a variety of things can prompt a claims denial. It might be a simple clerical error, like an incorrect address, or a doctor’s use of the wrong diagnostic or treatment code for your treatment.

Then there are the more serious causes — as when a treatment is specifically excluded from your policy, for example, or, as in Ms. Carr’s case, when the insurer deems a procedure experimental and therefore ineligible for reimbursement. Other frequently denied claims involve emergency room visits, especially those at out-of-network hospitals and clinics.

Another big category involves chronically ill patients, who often must try several medicines and treatments to find the one that works best for them. Such patients can become all too familiar with insurance denials, says Jennifer C. Jaff, founder of Advocacy for Patients with Chronic Illness.

But as Ms. Carr discovered, if you are denied coverage you have a right to appeal. And in most cases, experts advise you to do just that. Approximately half of all appeals are successful, according to anecdotal evidence from patient advocacy groups and data from individual states.

“About 53 percent of appeals work in our state,” said the Kansas insurance commissioner, Sandy Praeger. “That demonstrates that the process works.”

Use the following advice to increase your chances of success in appealing a health insurance denial. As you’ll see below, expert help may be available. And if you feel in over your head, and a significant amount of money at stake, it may even be worth hiring a type of specialist known as a billing advocate.

READ YOUR POLICY Always check your policy carefully before you undergo treatment.

Many denials are made because the policy specifically excludes coverage of a certain treatment, procedure or medicine, Ms. Praeger said. When it is spelled out that something specific is not covered, an appeal will not work.

TAKE YOUR TIME When you decide to appeal, do not act in haste, advises Ms. Jaff, of the patient advocacy group.

Most insurers allow a certain amount of time to file for an appeal, usually 60, 90 or 180 days. If you call and say I want to appeal, an insurer may consider that the appeal itself. So you want to take advantage of the time you have (without missing the deadline) to build your case.

Before you file, make sure you have all the information you need from your insurer to start your appeal in earnest. Your explanation of benefits should provide a code for the reason for the denial, and that code should be translated somewhere on the statement. If it is not or if you still have questions, contact your insurer.

Make it clear in your phone call or letter that you are not officially starting the appeal process. You simply have questions. If it is not already clear, you should also ask exactly to whom the appeal should be sent. (You do not want precious time wasted because your appeal was shuffled from desk to desk. )

Whenever you call your insurer, be sure to make a note of the time and date and the person you talked to. If you send a letter, send it registered mail with return receipt, and keep your own copy.

DO RESEARCH Once you learn why your claim was denied, customize your appeal to argue specifically against that reason. A clerical or coding error is fairly straightforward, but just to be sure, enlist the help of your doctor’s or hospital’s billing specialist to back you up with a letter explaining how the mistake was made.

Something more complicated, like an out-of-network emergency claim, will require proof that the situation was indeed a medical emergency and that no in-network provider was available. Obtaining your medical records can help support your argument, so can letters from the doctors who treated you.

Fighting a denial for something your insurer deems experimental can be the trickiest appeal. In addition to support from your doctor, you will need to find articles from established medical journals for evidence that the treatment is not only effective but safe.

You can find abstracts of many articles free on pubmed.gov, the library of the National Institutes of Health. Often the abstracts are enough to make your point. If you need the full article, which can be expensive, ask your doctor’s office for help or check with a local medical school library.

Any proof you can show that other insurers in your area cover the treatments in question can be valuable. Most big insurers list medical policies concerning treatments on their Web sites. Your doctor’s office can probably help with this, too.

You also must prove the medical necessity of a treatment, especially if it is considered experimental.

Ms. Jaff, for instance, learned this when she was denied coverage for a certain drug her doctor prescribed for Crohn’s disease. Her insurer argued that other, more established drugs could treat the problem. True enough, but Ms. Jaff had already tried those drugs without success.

For her appeal, Ms. Jaff collected her medical records that showed when she had tried each drug and how each had failed. The strategy worked, and her claim was ultimately paid.

Be sure to stick to the facts in any argument you make. Emotional or angry arguments, as much as they may feel warranted, will not help your case, said Erin Moaratty, who heads special projects for a group called the Patient Advocate Foundation.

GO THE DISTANCE Even if your well-researched and thorough appeal is denied, do not give up. You still have options, depending on the type of insurance you have.

If you receive coverage directly from an insurance company, say through a private policy or from your small or midsize employer, your insurer is regulated by your state’s insurance department. All but five states, Alabama, Mississippi, Nebraska, South Dakota and Wyoming, allow patients to have their appeals considered by an independent external review board, usually after all internal appeals have been exhausted.

In most cases the board consists of doctors and other professionals with an expertise in your condition. For more information on your state’s rules contact its department of insurance. To find yours, go to the National Insurance Commission’s Web site and click on your state.

Large employers that self-insure — meaning that they pay medical claims themselves, not through an insurance company — are not subject to state insurance laws. But most have provisions for external appeal reviews. Check your plan summary, the large booklet you received when you signed up for health care, for details.

GET HELP Your state insurance department can help answer questions and start an appeal. In addition, groups such as Advocacy for Patients with Chronic Illness and the Patient Advocate Foundation help seriously ill patients file appeals free.

Be sure to check the advocacy organizations for the illness you have. Many offer free advice on dealing with health insurance disputes with specific information related to your condition.

You may also want to seek help from a medical billing advocate (see our earlier column “A Guide through the Medical Wilderness”). Depending on the case, these professionals charge an hourly fee or a percentage of any recovered claim.

My PT Dilema

2010-02-02T13:05:00.002-05:00

I told a little white lie today at PT! I told my PT that I went with my friend to her PT and he gave me some exercises to try and some manual techniques to try.

At this point, I am 9 weeks out, the back pain is a lot better just since I have been doing the exercises I got yesterday at "secret PT" and since the "secret PT" worked on my hip.

My complete exercise routine is as follows: Upright Bike, Leg press, single leg press, squats on 2 dynadiscs, sidestepping squats with a theraband, standing hip 4 way with theraband (both legs), squats on a foam roller, seated isometric hip abduction and extension, seated knee flexion with theraband, seated knee extension with 2# weight, seated hip IR with ball and theraband, sidelying hip abduction and end range hip abduction, clam shells, bridges, quadruped hip extension.

My 3 new exercises are: 1)supine, operated leg straight, other leg bent with foot flat, theraband around both knees, operated leg doesn't move, other leg abducts/ER (fall outs) 2) double leg bridge, hold, pick up non-op leg, hold 2-3 seconds, bring it down, raise it again for 2-3 seconds, bring it down, repeat 10 times, then slowly lower bridge maintaining pelvis level. 3) standing on op leg only, bend forward by hinging at hips until torso parallel with ground, keep standing leg straight, arms out to side, slowly bring one arm down to your center and return to start position, repeat 10 times, alternating sides.

My PT is only stretching me and not doing a lot of manual work anymore, there are days when I really need it. the "secret PT" did such a great job on me yesterday, I am considering going back to him. Once I go back to work things will be complicated, but I would rather be complicated for a bit than not well healed. If only P, my original PT were still at my practice I wouldn't have these issues!!!

Secret PT Visit: Part 2

2010-02-01T21:07:00.002-05:00

Today was my follow up with my "secret" PT. I most likely will not be seeing him again, but he has been able to give me some great advice. It seems that my back pain is coming from muscle imbalances, mostly my glutes are super weak. He gave me 3 exercises to do for the next 10 days to activate the glutes and hopefully get me stronger and out of pain.

What's great is that immediately when I exercise, my back starts to feel better, so I know that by "waking up" my glutes, I start to move and function better.

In general my back has been better, I have increased my exercises in PT and added a few more challenging ones, and I had my back worked on 3 times last week. I still "spasmy" but definitely getting better.

I have to say that I know I post a lot less than I did for my previous surgeries, but life with 3 kids just wears me out, and by the time they are in bed, I am usually ready for bed too! I am still not back at work yet, but do find myself busy all the time. I plan on returning in 3 weeks. I will be working my regular, part time hours. I agreed to cover someones maternity leave in another office. It would be managing the office and working three 12 hour days....I hope I don't regret it!!

Goodnight Nobody

6 Days Out From Shoulder Surgery

Shoulder Surgery Tomorrow

Happy New Year Aetna Members

26 days post-op

Outing to Jks 6th Birthday Party

Op Report #5

Post op Appointment x 5

Having a Meltdown

PT day 1

My Little Helper

What My Day Consists Of

Surgery#5........ Done!

Surgery is still going on

Surgery #5...Tomorrow

Fighting for out of network reimbursement

T-10 days

Aetna's policy #0736 is UNFAIR and UNETHICAL

Sodium

The Stress is Killing Me

Shoulder Update

Why Why Why

The Pre-op Appointment

I Scheduled It...AAAHHHHHH

More Problems With UHC

The Plan...Finally

The Second Opinion

What A Long Journey This Has Been

Thinking and Worrying

MRI # 7 Report

Psoas Release...something to consider

MRI Verdict

Micro Instability???

Or Is It?????

Wow, PT is working!

Taking a Different Approach

Video Presentation on the Ligamentum Teres

PT...Again

The Latest Appointment, Still No Answers

Turning Point

And The Saga Continues

Hip Injection #8...done

Why Why Why

Still No Answers

It's Official, My Shoulder Officially Sucks

Hip MRI #6...done

##$%#&* Right Hip

The Good and Bad News

Popping In To Say Hi

New 2011 CPT Codes for Hip Arthroscopy

Aetna and FAI 2

Double Update

Cost of Hip Arthroscopy has been updated

Cortisone Injection # ?????

Shoulder...

Massage...Ahhh!!

Running...Again

Shoulder Update

Shoulder Now.....Please Make It Stop

Aetna and FAI

Hip Issues and Incontinence

Checking In

5K Training...taking a break :-(

When in Doubt, Find An Experienced Surgeon

"The Recommendation...And What I Am Doing About It

Am I Micro Managing?

Time Flies When You're Having Fun...

Yes, I Won My Appeal

The Exercises

Problem Solved....Or So I Hope

I Have Reached A New Low In Life

The Pow Wow

And the Saga Continues...

Ultrasound Report

Sometimes Even I Can't Believe that These Things Happen To Me

UHC: 0 Susie: 1

Stepping on Glass Was One of The Best Things I Could Have Done

Now Its Tight...

Timeline Recap

Hip MRI #5