Muscles? What muscles?

I was getting dressed yesterday morning and was beyond shocked at what has become of my leg. Since children I have given up on the gym but I have always been muscular. I think atrophy would be too "light" of a word to use. My muscles have disappeared and been replaced with fat..... Or maybe jello. It's only been 3 weeks but my legs are un-identifiable to me. Will they ever return????

Post-op Appt

Post Op Appointment I went in to my first post op appt with one goal in mind- to discuss pain control. This week has been pretty bad and the Norco I have been taking just wasn't cutting it anymore. I had to go back and add in Percocet and I was taking a lot of pills. My OS was very pleased w my progress but not happy with my pain levels. He offered me Dilaudid which I felt was way to strong for me. He told me to try it since some people respond differently to different drugs. So I reluctantly accepted the prescription and had it filled immediately. I have to say it is my new wonder drug. As I write this it is 430pm, I took one pill at 7am followed by 2 Tyelnols at 11 and am having the best day I've had all week. I'm also taking Lyrica 3x/day and icing as needed. I definitely have some side effects from it, in the morning I felt a little woozy but nothing like the way I feel on Percocet. Functionally, nothing has changed. I still basically lay around all day. I can't drive and sitting is uncomfortable. I know that this is the norm but its a tough pill to swallow for me. My kids are off from school next week which will make for a very interesting week.

2 weeks Out From Open Surgical Dislocation

The last 2 weeks have been pretty rough and I'm not sure how prepared I was for this. I knew this surgery would be like no other but I must say the recovery has taken me by surprise. The pain is not horrific but I most certainly need my pain meds. The pain is mostly lateral, in the place where I imagine my leg was sawed and screwed back together! I have started to be able to sleep on my non-op side w pillows between my legs but the angle has to be "just right" or I start to feel a lot of pulling laterally. I spend the majority of my day in bed still. Over the last few days I have been able to tolerate sitting at the table for dinner. Everything is exhausting. I left the house for the first time on Friday for an acupuncture appointment. It is about a 2 min drive but I was worn out and paid for it the next day with increased pain and swelling. I have been using my CPM a few hours/day. I don't find it as helpful as I did after my last scope but I am using it. I am completely unable to care for my kids, luckily my mom is still here running he show. I have a toilet seat riser and a shower bench that are a must after this surgery. My incision has to stay dry until I see my OS so I cover it with tegaderm when I shower. I know my blog used to be a lot more detailed and I never held back info, I will try to provide all the info I wanted pre-op. You can always email me for more Info. One of the things that stressed me out pre-op was what to pack for the hospital. I'll give you a list of what I decided to pack and then I'll tell you what I used! Of course I was concerned about post-op underwear. I'm sure there are many people who found this blog post just by googling those words! I had 2 hip friends recommend 2 different things, one recommended men's boxers and one recommended Victoria's Secret string bikini as the band wouldn't touch the incision. I went w the string bikini and have been very happy w that choice. So I packed a few pairs of underwear and few pajama sets (pants and shirts), a robe, a sweatshirt, socks, bras, toothbrush, toothpaste, mouthwash, deodorant, dry shampoo, lip balm and hand cream. Additionally, a friend gave me a pre- surgery care package with sucking candies, a silk, flax seed filled eye pillow/ mask, and a few other toiletries. I also packed a loose pair of sweatpants to come home. I had no dressing on the incision by the time I came home but there was significant swelling. I wore nothing but a hospital gown the entire 4 days. Surgery was Monday, the catheter came out Wednesday. At that point I had no energy, or a care in the world. I started using a bedside commode that day and couldn't even imagine having to remove clothing. The first time I tried on my new underwear was when I got dressed to go home! I used my toothbrush and toothpaste (the hospital provided but I prefer my own), deodorant, lip balm(all day), hand lotion and sucking candies. I didn't touch the dry shampoo- the morning of my surgery I washed my hair twice and blowdried and flat ironed it hoping to get a long run out of it. It worked. I also recommend to anyone going into the hospital to get an eye mask. It made a huge difference. All the clothes I packed remained un-touched. I laugh now at how stressful the "packing situation" was when in the end all I needed were some comfy hospital gowns! I keep wondering when my leg will stop feeling "broken". Hopefully soon and hopefully I will be cleared for increased weight bearing soon!

Open Surgical Dislocation....Over

I had my open surgery 5 days ago. For the entire week prior to the surgery, I was a mess. I was constantly on the verge of a panic attack. The only reason I was able to finally calm down was because of my acupuncturist who is the most amazing woman I have ever met. If you live in the NYC/lower Westchester area I highly recommend you see her for just about any ailment. http://www.acupunctureforlifeny.com/ I see her for anxiety, which is directly related to this surgery. The Monday before my surgery I was feeling panicky so I stopped by her office so that she could put in tiny needles in my ear at points that help me control my anxiety. I felt so much better the next day. Maybe it is just a placebo affect but when I went for pre-op testing in Wed, I was expecting my blood pressure to be through the roof and it was normal. I couldn't believe it. I saw her for a full treatment Thursday and on Monday, the day of my surgery, it was still normal. My pre-op blood pressure is usually really really high! I was on the same floor that I have been for my previous 5 hip surgeries and my shoulder surgery. I was surprised they didn't have a sign that said "welcome back Susie"! I got my favorite nurse who in the past has been a goddess getting my IV started. Unfortunately this time my veins weren't cooperating and it took 3 times to start my IV. The other difference was that I had to put on TED stockings prior to the surgery to help w my circulation. The surgery was done using a spinal epidural and sedation with the anesthesiologist maintaining low blood pressure to prevent too much blood loss. I was brought to the OR around 430 or 5. The next thing I remember was waking up in horrific pain, probably the worst pain I have ever experienced in my life. I was so nervous about this happening and I had a long discussion abt it w the anesthesiologist and with my surgeon's PA. The floor I had surgery on is where mostly the arthroscopic surgeries happen. The bigger surgeries happen on another floor. I was afraid the PACU wouldn't be able to handle me! It took 2 hours and whole lot of dilaudid to get me comfortable. Once I could think I realized that the epidural had worn off on the right (op side) and not the left. Not good! I had a pain pump w Dilaudid in it so they kept telling me to press the button on it. I don't think it helped too much though. At around midnight they moved me to the PACU on the floor where they do the "real" surgeries and I spent most of the night there. The nurses was great and let J stay with me since there was only one other patient in there. I began to feel very itchy from the meds so she gave me some Benadryl in my IV. I had a strange reaction and began to cough. We didnt think much of it and it worked so quickly I just fell asleep. By around 5am I could move my legs an acceptable amount and was transferred to a room. I was comfortable and in no pain as long as I didn't move. I had a urinary catheter and an epidural still in place. The pain pump went right to the epidural and the catheter was a blessing in disguise because there was no way in hell I was getting out of bed to use the bathroom. I was getting meds round the clock, I don't know why I was getting some of them but I was too out of it to question or argue. I was getting iron, a multi vitamin, aspirin, Percocet, toradol in my IV, Zofran in my IV and Nubain in my IV for itching since I had a weird reaction a second time to the IV Benadryl. As far as the surgery went, I have spoken w my OS a few times but need to get the op report to know exactly what he did. From what I understand, the old allograft had actually incorporated nicely but wasn't functioning at all. It was pretty easy to dislocate my hip. Once he put in the new one it created a good seal that could be seen since it was an open surgery. I think he also said he shaved down bone under my psoas but I will have to confirm this when I am less drugged. The epidural and catheter came out on the 3rd day and I began using a bedside commode since I wasn't doing great in PT. I think I got as far as sitting at the edge of the bed and standing on the second day. The 3rd day I took a few steps and made it from one side of he bed to he other. By day 4 I was feeling a lot better and really wanted to go home. I pushed myself in PT and walked far enough to make them happy and did a few steps. The best part of coming home was taking a shower. I got to use my fancy shower bench and I have to keep the incision dry until my OS can check it, but it was a real shower! My incision is closed with dissolvable sutures and steri strips. Since I've been home I have spent most of the time in bed with my CPM. I have to take aspirin and wear TED stockings to prevent blood clots.

Post-op

Cleared For Surgery

I am officially cleared for my open surgical dislocation on Monday  I saw my OS yesterday, had pre-admission testing and medical clearance. I am good to go.

I was already pretty familiar with the procedure thanks to 6 years of dealing with my hip and google :-). A few things I had questions about he clarified though. The old allograft will come out completely with all the anchors and a new one will replace it. The old one is a semitendinosous tendon, the new one will probably be a post. tib tendon, they tend to fray less. The restrictions will be no active abduction or passive adduction. The flexion restriction will be determined in the OR based on when the labrum engages. Additionally, the capsule will hopefully be able to be reconstructed with my own tissue. The advantage of the open procedure is that the surgeon can actually feel the tissue rather than just see it with the scope. If it is of adequate quality it will be used to do a good, open reconstruction. If necessary, there will be a synthetic material on hand to support it.
I will have 6 weeks of protective weight bearing and no driving for about that long as well. 2-3 nights in the hospital, CPM, no brace.

I think that covers everything! Wish me luck.

Open Surgery Scheduled

December 3rd.....details to follow

MRI #10

History: right hip pain. Clinical concern for instability. Status post multiple arthroscopic procedures including labral repair and debridements of the ligamentum teres.

Findings:
Comparison is made to MRI of the right hip dated 5/8/12
MRI of the right hip was performed utilizing large field of view coronal fast inversion recovery and axial fast spin echo, as well as surface coil coronal, sagittal, and oblique axial fast spin echo techniques.
There is no acute fracture or osteonecrosis.
Surface coil images of the right hip demonstrates Osseous debridement of the anterior femoral neck junction, unchanged when compared to last MRI. There has been rim debridement of the labrum with superimposed labra repair. The labral remnant is blunted and degenerated. There is erosion around a fixation device located in the anterior superior acetabulum, which demonstrates slightly more prominent bony erosion when compared to the prior exam. The iliofemoral ligament is hyper intense and deficient, particularly at the anterior margin of the joint. The ligamentum teres is markedly attenuated. This constellation of findings is consistent with features of micro instability of the hip.

There is borderline coxa valga. There is moderate wear of cartilage over the subfoveal anterior margin of the head and anterior wall, unchanged since 5/8. There is also high signal within the cartilage overlying the posteromedial femoral head, with partial thickness chondral loss, and additional cartilage loss laterally in the area of debrident. There is no extensive bone on bone contact or bulky synovitis.

The short external rotators are preserved, as is the posterior footprint of the gluteus medius. There is degeneration of the anterolateral footprint of the gluteus minimums insertion, without tear. There is mild insertional tendinosis of the iliopsoas without tear. There is no iliopsoas or ischial bursitis. The previously noted fluid within the greater trochanteric bursa has resolved.

The hamstring origins are symmetric. The pubic symphysis is preserved a are the abductor origins. Fat planes surrounding the sciatic nerves are preserved. The femoral neuro vascular bundles are maintained.

Impression:
MRI of the right hip status post Ossetia debridement of the anterior femoral head neck junction and labral repair demonstrates findings compatible with micro instability of the hip deficiency of both the anterior margin of the iliofemoral ligament as well as the ligamentum teres.
Ossetia resorption surrounding a fixation device in the anterior superior acetabulum has progressed since the prior exam.
There is moderate cartilage wear, preferentially affecting the femoral head.

MRI results and discussion with my OS

I got my MRI results on Thursday and was not too happy. (I will post the report later). In short, my labrum is degenerated, one of the anchors holding it in is not really holding, I have evidence of micro instability and have cartilage damage that has progressed since my MRI in may. I was freaking out all day Thursday, I couldn't believe the changes in the MRI in just 4 months and that I was unstable again. I sent my OS an urgent email that I NEEDED to speak with him. I knew he was going to the hip meeting the next day but I was so freaked out I didn't know what to do. 

He called me the next night and went over the MRI with me. The labral allograft clearly wasn't working and my ligamentum teres was once again all stretched out. He had discussed my MRI with second opinion OS but wasn't actually able to look at it with him bc of computer issues. He would do that the next day and go over it with other colleagues he trusts. 

He feels terrible and says I am the victim of a learning process that has gone on in the field of hip arthroscopy, he said had I come to him just a few months later I would probably not have gone through all of this. His reasoning for the last scope failing was that possibly the fluid medium during the scope affected the allograft, scopes are done with fluid in the joint to help with visualization. 

What we both agree on is that I will not have another scope to fix this. The only way to do it now is with an open surgical dislocation so he can have full access to the joint, full view, do a very very thorough assessment, a high quality labral reconstruction and a full capsule repair. 

I have been thinking about open surgery for the last few weeks so I was well prepared for this conversation, held it together and was in complete agreement. 

My OS is supposed to call me back after reviewing the new MRI at the conference and I guess we need to discuss details and timing etc. 

As far as timing goes- it couldn't be worse, I just started my own practice and don't know exactly how I will take so much time off. I guess things have always worked out in the past so they should work out this time too. I just want to close this chapter in my life and move on. 

And the Saga Continues.....

As "luck" would have it, my last injection was of no help to me and things seem to have taken a turn for the worse. Standing is painful which is not good given what I do for a living. The pain has just gotten to a point some days that it is now unbearable. I sent my OS an email to let him know and hoping he would let me know he had spoken to the second opinion OS. He responded that he had been emailing back and forth but hadn't yet spoken to him but will soon and will let me know. A few days later he must have changed his mind because he decided that since my pain had gotten so bad after the last injection, we should move up my next MRI to now, and to do it before the IHSA conference this week where all the top hip scope surgeons will be, so that he could review the scan with colleagues as well as second opinion OS.

So today is MRI #10......my valium is packed and I'm ready to go. I don't know what the best and worse case scenarios are for this but I guess all I want are answers. I asked him what specifically he is looking for, he said "integration of the labral allograft"...not sure what he plans on doing if it isn't "integrated"....

Another second opinion

I had a phone consult last night with another OS. He is "sure" that I have a delamination defect of the cartilage of the acetabulum. (I will put in an article abt it). He sounded pretty certain abt it, he said he sees it a lot in ppl with continued pain after hip scopes. I asked him why my current OS wouldn't see this, he said "you have to know to look for it". He also thinks my new labrum is not functioning and not providing a suction seal. He would like to go in and repair the delamination defect by microfracturing under it and anchoring it down and removing the new labrum and re-creating it again (I think). I clearly am not to happy with this, a 5th surgery? Seriously? I asked him if he thought this could wait, he said if I was within a comfortable pain zone yes but if I was in a lot of pain no bc it meant I was doing more damage. Well, let me tell you something, I don't reach out across the country for second opinions if I am not in a lot of pain.
He also suggested I not have surgery with the same OS again, or, if I chose to, to make sure that he spoke with him. I didn't like that surgery was the only option, I don't think he did either, he kept saying how bad he felt for me. To be honest, I don't need anyone to feel bad for me, I always say there are no "feelings" in orthopedics, just go in and fix it!!
I was clearly not about to hop on a plane and let him operate on me based on a phone conversation, and a diagnosis that he can't prove or see but feels strongly about. So I asked him if he'd be willing to speak to my OS and discuss this with him, bc really, no one knows what the inside of my hip looks like other than him, he's seen it 4 times. He said he'd be happy to so hopefully they will speak in the next few weeks. I did warn my OS to expect a phone call from him, and he said he'd lookout for it and let me know once they spoke. So once I know what is going I will report back!

http://hiparthroscopy.net/pdf/publications_lectures/Arthroscopic_Treatment_for_Chondral_Lesions_of_the_Hip_T_G_Sampson.pdf

Family Update

Its been a while since I posted pics here and we recently had a really fun photo shoot in the park! When I started my blog, L was 2, Jk was 1 and Zk wasn't around yet! Now L is 8, Jk is 6 and Zk is 3. And I am no longer 26!!!

8.5 month follow up visit with OS

I saw my OS yesterday for a follow up visit and to discuss"what next????" He showed me my CT scan as he  ran it through his surgical planing software and showed me that no where is there any angle that is not normal, all the coverage angles, center edge angle, version etc is all within normal limits. The left, which is still pain free after 5+ years does not look as perfect, he actually said that if my left were bothering me he would be able to find places to take down bone...no thank you! The only possibility that he sort of brushed over is that my new offset on the right may be too much FOR ME, but obviously you can't put bone back and there is now way to know for sure.
I asked him to check my capsule again on the last MRI- he thought it looked ok, but its hard to really see if it actually stretched out or not but it is not torn. He would like to wait 3 more months and possibly get an MRA since injecting gadolinium will stretch the capsule and then he would be able to really get a god look at it, he also wanted to re-image the graft at that point since it was still immature at the last scan. He also wants an MRI of my left just to compare. He is hesitant to go with the MRA because he is pretty certain it will be very painful for me since I have a lot of irritation in the joint and the gadolinium is acidic, I said I'd rather just do it, than have a regular MRI and then find out we need another one. I guess I have a higher pain tolerance than a claustrophobia tolerance.
We spoke about the 'what ifs' and later on the 'whys'. If the capsule is indeed very stretched out...again, he would want to do an open procedure to support it with a mesh scaffold. The why is not known- possibly a collagen issue that is aggravated by the surgeries...the only way to know is to go see a geneticist who specializes in these things. I think its pointless since it won't change the course of treatment or outcome.
I told him I need a quick fix now- I have so much pain some days it makes life very very hard, and I can say that in the last few weeks there have been more than several times that I felt like I was going to lose it, including in his office yesterday. I asked if he'd let me get another cortisone injection. He agreed but said to add Orthovisc to the mix to lubricate the joint. Fine. I was able to have it done yesterday, this time it was ultrasound guided- all my other ones have been fluro guided. I have to say this was soooo much better, I was in and out in 15 minutes.
After the injection I had the "full" feeling in the joint and nerve pain down my leg, I was reminded by a fellow hip friend that the same thing happened last time and she referred me back to my blog for verification!!! I am hoping I get some long term relief from this. We think the issue is that the capsule is too loose and the joint is unstable and sliding around, causing inflammation and pain, so an injection is obviously a bandaid since it will take care of the inflammation and pain but not the capsule.
We discussed the possibility of another PRP injection, this time to the capsule, we ended up agreeing that it wasn't worth it at this time.
On the issue of my son, his bone scan was normal. If he continues to complain we will get an ultrasound to look for inflammation!

8 months post op

I once again apologize for neglecting my readers for so long. My practice is taking up a lot of my time but in a good way. I am incredibly busy, working hard and seeing a lot of patients. 
On he hip  side of things, my cortisone injection has worn off completely and I am back in a lot of pain. Mostly posterior joint pain. I have looked into several things as well as other opinions. One person posted on my blog abt a year ago regarding the possibility of bone growth in the back of the joint. I have been bugging my OS abt that. I have also sent my scans out for a second opinion, hopefully I will hear something by the end of the week. I also see my OS in 1 1/2 weeks. 
In other things hip related, my 6 year old started complaining of hip pain about a month ago. He was limping and complaining of groin pain. I obviously freaked out and wasted no time getting him an appt with a pediatric hip specialist. Initially he diagnosed him with toxic synovitis, which is when a virus settles into the hip joint and causes inflammation. 3 weeks later the pain was still there and now a line showed on his X-ray, right on the femur. The OS wants him to have a bone scan to see what is going on and then will decide if he needs an MRI. Never a dull moment in my home!

Acupuncture for Hip Pain

Since I was having such great success in acupuncture for anxiety, I decided to give it a shot for hip pain. My acupuncturist was willing to try it and I have such great faith and trust in her I went along with it. I don't know if I have expressed this on my blog but at this point I don't let ANYONE touch my hip, manipulate my hip, massage my hip, stretch my hip...you get the picture. I think I have been through 7 PTs to date and I clearly have trust issues at this point.
My acupuncturist started by feeling all the muscles surrounding my hip joint, noting that every single one was tight, tender and full of trigger points.The worst offender was my QL, which has been worked on by many PTs before only to lead to more problems. I knew this, but still, I let her try to treat me, I figured this was a different type of treatment.
At the first session, she needled all the tight and tender muscles in my hip and back. It completely de-stablized my hip and made my pain worse for days. My muscles are tight for a reason, and working on them is not helpful to my hip joint as they need to stabilize an underlying unstable joint.
The next time I told her what happened so she stayed away from the majority of the hip muscles but worked on the QL. When she removed the needles she said the area was very red meaning it had increased blood flow, or something like that :-) So she put in more needles (the kind that stay in all week) into the QL to maintain the bloodflow. Again, this completely destabilized me this time causing thoracic pain too.
So what is the solution? I have no idea. I just sent my OS an email asking him to re-review my CT scan and x-rays and figure out what the problem is!!!!

6+ Months Post-OP

Wow, I have really neglected my readers so I sincerely apologize. Luckily, I have been extremely busy with my new practice and some days barely have time to breathe. As I previously wrote, I was having a period of intense anxiety with real, physical manifestations including heart palpitations and occasional high blood pressure. I have been able to almost completely control this with acupuncture treatments. It is such a wonderful feeling to feel like I am back in control of my own body. The first time I went, I was lying on the table and could feel my body relaxing, as I completely relaxed, pain crept back into my hip. As the anxiety has gotten under control, and as I have increased the number of hours I work, the pain in my hip has returned. If I had to choose anxiety or hip pain, I would choose hip pain any day.

I actually spoke with my OS last night and the only way I could explain it to him is that "my hip doesn't fit me right, it is still feeling too 'loose' ". He is at a complete loss and his only suggestion is to try PRP or prolotherapy into the capsule and hope it scars down. I am not doing anything at the moment, I have way too much going on with work, I am extremely overwhelmed with the responsibility and time it takes to make a new  practice successful...but I am loving it!! The PRP in my hamstring was a smashing success but I had 2 weeks of really bad pain, I really can't afford the downtime right now. I am scheduled to see him in 2 months, at that point I will re-evaluate the situation and if I am still in pain, possibly consider the injection. The cortisone was great while it lasted but I can't get another one yet, and its probably not a great idea if I want to preserve my hip in any way shape or form.

Finally Some Relief

I don't know if it was the multiple massages last week or the distraction of my practice, but I am finally feeling better this week.I have also had a ridiculous amount of anxiety, which causes me to feel no pain at all, so I guess I have to pick my poison!!! Its hard for me to really know what is helping as I have always had good days and bad days and for no apparent reason, but I have had a bunch of good days in a row so I am keeping my fingers crossed!

I saw my OS today and since things seem to be better at the moment I didn't really press any of the issues I have been having. He did review my MRI with a hip MRI specialist and she thinks there was a good deal of synovitis in my joint. It could be a reaction to the allograft or part of the normal healing process. She did recommend a new MRI in 6 months just to check on the progress of the healing of the allograft. There is still some fluid in the joint but not too much, the capsule is intact. In my opinion, this is going to require more time to heal. My OS said normal tissue takes 3 months to heal and this is by far normal tissue.

The one thing that doesn't thrill me is the amount of ER I have in the right hip. My OS is not all that concerned but it doesn't feel normal to me. He attributed it today to a differece in version angles between my right and left hip, right is 6 degrees and left is 13 degrees, making it more likely to ER. I don't really buy that answer right now, especially because the left has some acetabular retroversion so the 2 hips should be pretty equal.

One thing I keep telling myself is that this is no longer a normal hip and I can't expect it to do normal things. It has been operated on 4 times, it will never be the same again. I think in another 6 months we should know if the surgery was successful and how much permanent relief I will have.

I am Just Completely Worn Out With This

Interestingly, my husband and I bought our current home in 2006, immediately after, things started to go downhill for me health-wise. That was when I was officially diagnosed with Crohn's and immediately after that, FAI. You know the FAI story......It seems that the previous owners developed a liking for multiple mirrors, and my house is lined with mirrors, in a lot of places, and in a lot of places where you wouldn't ordinarily expect a mirror (bathroom ceiling???). My point is that I can't even walk from my bedroom to the kitchen without having to catch a glimpse of myself, and what I have noticed is as time has gone by, I am just looking completely worn out. I do think I do an excellent job of not letting see what is going on, I don't have a visible limp, I am able to attend PTA events, social outings (usually), my kids' sporting events, but the toll this is asking on me is becoming quite evident to me in the multitude of mirrors.

I sent an email of desperation to my OS last week. We spoke on Fri, I am not sure what he really thinks is going on but he said he wants an MRI of my hip, to see what is going on and why it responded so well to the cortisone, and to get an image of the tissues etc. He also said he wants one of my back. I said look, I don't think there is a problem with my back, I am pretty sure it is all coming from my hip, but if you feel strongly about it then I will get an MRI of my back too. He decided to wait until I see him in 1 1/2 weeks to make the decision about my back. He thinks that at this point my problem has now become even deeper and is a neuromechanical problem. He said he thinks I am having trouble finding a balance in my hip, and that is why I go from hip to back pain over and over again.  This article may provide insight into what that means.

The layer concept: utilization in determining the pain generators, pathology and how structure determines treatment.

Draovitch P, Edelstein J, Kelly BT.

Source

Hospital for Special Surgery, 525 East 71st Street, New York, NY, 10021, USA, draovitchp@hss.edu.

Abstract

The level of understanding of pain in the non-arthritic hip has made significant strides in the last couple of decades beginning with the discoveries of Reinhold Ganz, MD. However, even with the detection of subtle bony abnormalities, including femoroacetabular impingement, a clinician's ability to differentiate pain generators in the hip has been ambiguous. Deciphering the etiology of the pathology versus the pain generator is essential in prescribing the proper treatment. The Layer Concept developed by Dr. Bryan Kelly, is a systematic means of determining which structures about the hip are the source of the pathology, which are the pain generators and how to then best implement treatment. Four layers will be discussed in this article. Layer I, the osseous layer, Layer II, the inert tissue layer, Layer III, the contractile layer and Layer IV, the neuromechanical layer.

PMID:

 

22371303

 

[PubMed - in process]

 Of course this is what they know the least about at this time. He also spoke about finding a PT that I can work with, that will WORK. I said its been 5 months, I'm pretty sick of PT and I really don't want to be in PT for the rest of my life.He agreed with that. I asked if I should go back on Lyrica, he said to try it and see if it helps. I also had an acupuncture treatment 2 nights ago, it definitely helped the spasm in my back and I slept better than I had in weeks. I also had a massage 3 days ago but I might as well have flushed the money down the toilet. What was interesting though was that it actually helped the pain in my back temporarily but made the pain in my hip worse.

What I started doing to help my pain and core is a series of exercises that I have been using on my older patients, those that are either low-functioning, are post-op from spine surgery, have osteoporosis etc. I find that while I am doing them I get pain relief, so I will continue. they are from a book called "Walk Tall" by Sara Meeks. I highly recommend this to anyone who is having back issues that are not responding to any other therapy. These are simple exercises, each one very carefully and specifically explained with pictures, they are easy to do and easy to follow, I keep the book with me when I am treating.

So the current plan is Valium+MRI, see OS to review MRI and possibly obtain back MRI.

Post Injection

It has been a week and a half since my cortisone injection and I am happy to report that the pain in my joint has finally decreased. I actually feel human again and have been functioning normally the last few days. The pain in my back is not gone though, but the referred pain to my lower leg is improving. One of my greatest achievements is finally coming to fruition, I have started my own private practice. This comes just at the perfect time, sometimes life works in mysterious ways! Check me out www.hudsoninhomept.com
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The Injection

If there is anything I have learned up until this point is that my hip is no longer a normal hip and will not respond to treatment the way normal hips do. Case in point, my cortisone injection last week. This was the 10th time I've had an injection into my hip so it no longer phases me.  I got good relief initially from the local anesthetic. At the 2 hour mark I started having posterior joint pain. At first I assumed that this pain was just something that would not be affected by the injection but a few moments later the pain in my entire hip became so bad I don't know what had hit me. I couldn't believe I had only gotten 2 hours out of the local. A little while later the pain subsided and I got another hour or 2 of pain relief. For the rest of the day I had a terrible headache and was breaking into a cold sweat. I think I may have had some sort of reaction to the steroid.  The next few days were pretty rough, I've been taking narcotics and muscle relaxants and some anti inflammations which I usually avoid. Again, my anterior hip muscles are in such bad spasm that they are pulling on my back and now I am having really bad back pain. The back pain is a lot more debilitating than the hip pain, IMHO. Additionally, to complicate matters, when my hip pain is bad, I am getting referred pain into my calf. I don't know if this is related to the nerve injury from the surgery or something different The last few days have been immensely challenging for me. I could barely get out of bed yesterday due to pain and then due to me not being able to function on narcotics. Today I tried taking it easy again but tomorrow I have to live my life and move forward. I am at a loss and don't know what to do, what to think or what will happen with my hip.  I haven't worked in almost 5 months. Initially I was on disability. When I thought I was ready to return to work, I found out I no longer have a job. This definitely threw me a curve ball. For a while, I have been thinking about starting my own practice and this was the kick in the pants I needed. I have been planning and am almost ready to start, I am hoping and praying that u can be successful and that my hip problem will not stand in my way. 

4 1/2 Months Post-op

As my hip journey continues to drag on, my hope for normalcy is slowly fading away. I have pretty much lost faith that there is help for my hip and am trying to  tell myself that I would be better off with a hip replacement in the near future.

Last week I sent my OS an email asking him for a cortisone injection, I hope to be able to have it this week. I also am quitting PT (again). I can't stand the thought of spending my entire day going and coming, and being in worse pain for days after. The price is also becoming prohibitive with a high copay and city parking prices. My hope is that the cortisone takes the edge off and I can take my mind off of this for some time.

PT, besides for irritating my hip, is also causing me back pain. I think that my hip is still unstable and the anterior muscles go into spasm to try to stabilize in turn pulling me into excessive lumbar lordosis. I had to ask my PT to please not sacrifice my back for my hip!

CT Scan Results

Right Hip

Maximum alpha angle (9:30): 44 degrees
Coronal Center Edge Angle: 29 degrees
Sagittal center edge angle: 62 degrees
Femoral neck shaft angle: 146 degrees
Acetabular version: (1:00) 11 degrees
Acetabular version (2:00) 15 degrees
Acetabular version (3:00) 20 degrees
Femoral version angle (6 degrees)

Left Hip
Alpha angle: (1:00) 49 degrees
Coronal center edge angle: 36 degrees
Sagittal center edge angle: 57 degrees
Femoral neck shaft angle: 132 degrees
Acetabular version (1:00) -6 degrees
Acetabular version (2:00) 12 degrees
Acetabular version (3:00) 18 degrees
Femoral version angle: 13 degrees 

CT Discussion

I spoke with my OS a few nights ago to go over the CT scan. Overall everything is pretty normal (will post numbers soon). My right hip is a tad more shallow than my left but still normal. The right is also a little more retroverted than the left, but within normal. He still stands by his theory that the problem is a neuromuscular control issue and more/ more consistent PT should help. I am seeing a new therapist since my PT has drastically cut back his days/ hours and I can't see him on a consistent basis. My OS said he would come to PT the next day to speak with my new PT and go over things with her.

My new PT initially had to undo the damage from last week, get me out of spasm and realigned. Then she worked on core control and glute control, saying I don't fire my muscles in the proper order unless she cues me to. She did release some of my hip muscles a little bit, including my psoas, iliacus and obterator. It didn't change the level of joint pain. It was discouraging that some simple exercises increased the joint pain. My OS came by and once again discussed my hip angles, assured me he didn't take down too much bone and reinforced his theory about the neuromuscular control. The plan is to see this PT for 4 weeks in a consistent basis and see what is happening at that point.

A Concussion In My Hip

That is what I am feeling. According to WebMd, a concussion is a type of traumatic brain injury that is caused by a blow to the head or body, a fall, or another injury that jars or shakes the brain inside the skull. I feel like my hip is in a constant battle inside the joint, slamming into the front and back side of the joint, causing groin pain or butt pain. I can address one but then the other returns.

My PT has taught me how to get the femoral head back inside the socket, or at least to move it back a little and it alleviates the groin pain. But what has been happening is that the posterior pain returns and the anterior muscles go crazy, the spasms I have been having are breathtakingly painful. I have been taking Baclofen like candy the past few days to try to get some control over this. The spasm go into my back as well so along with hip pain I have developed back pain too. I'm going to try to not do the repositioning exercise today and see what happens.

I am supposed to speak to my OS on Tuesday to go over the results of the bilateral CT scan that I had last week. I will keep you posted.

Me and Zk

Sometimes You Have To Keep Trying

My poor physical therapist works so hard when I see him to try to find a way to make my pain decrease. I am 3 1/2 months post op and things recently took a turn for the worse. Today, after almost a month of pain, he was able to give me some relief.

His theory is that my femur sits too anterior and is causing a lot of problems for me there. Why it sits too anterior I'm not sure (I will get the answer from him tomorrow). So what he had me do today was increase the coverage of the femoral head by rotating my pelvis over the femoral head. It worked!!! My pain level decreased significantly (this was after many attempts at different exercises and different manual techniques). It has been 2 hours since I left him and I'm not 100% pain free like I was then but I am feeling a lot better. He is also having me do abdominal setting/ bracing exercises to try to help keep the femur in proper position.

I had my CT scan yesterday and wont be speaking to my OS until next week.

I had this "anterior femur" thing before, it was a problem after my last surgery as well. It makes me believe even more that my acetabulum may be a bit too shallow now since the femur keeps wanting to come out. I hope to god that I am wrong bc you can always take more bone off but you cant put it back on :-(

A Look Inside My Head

As I have been telling you, I have been in a lot of pain. I have had a lot of free time on my hands lately and just a little too much time to think about things. Why does my hip continue to return to being painful? What are we missing? Is it possible that too much bone was taken down from my right hip? There is definitely more bone on my left hip and my left hip is great. I did ask my PT last week but I think I made him uncomfortable with that question. It's a tough question, an uncomfortable question. But it had to be asked and I had to get it out there.
I broke down on Monday and emailed my OS. I know something is not right with my hip, I'm having a lot of joint pain, in the groin and the back of the joint. At times the pain is unbearable. We spoke tonight and he immediately blamed my dysfunctional muscles. He wants me doing more PT ( my PT only works every other week right now) and getting more hands on treatment. We got around to discussing the bones and comparing both sides, and I just came out and asked him if it's possible that too much none was taken down from my right hip, resulting in all of these issues. In a nutshell, he doesn't think so but wants me to get new bilateral CT scans to really see what the 2 sides look like and compare them. We finished the conversation with him assuring me that we both have the same goals in mind, to get my hip to stop hurting and to keep me out of the OR. I replied to him that I want him out of my life just as much as he wants me out of his life!!!

Not Happy

About a week ago I mentioned that I'm having a flare up in my hip. It has not gone away :-( it has progressively gotten worse. My first day of PT this week was incredibly unproductive, everything we tried hurt. I was so sad and frustrated. I had been doing so well for such a long time. My second day of PT this week went better and we found that avoiding exercises in the sagittal plane was the key to reducing my pain. Things went much better but the next day I woke up in horrific pain. I seem to be in a cycle of pain that is so intense and irritating, inside my joint, that it brings me to tears and narcotics. Then, I can feel so much better without doing anything specific. It is a terrible cycle that I can't break. I told myself I'd give it until the end of he weekend and then decide what to do. I am not happy.

2 weeks since PRP

I don't know if it's too soon or if this is the placebo affect but I don't really care, I CAN SIT !!!!!

3 months post op

It has been 1 1/2 weeks since my prp injection to my hamstring and 3 months since my surgery. Initially after the prp injection I had soooo much pain. It has resolved and I am finally feeling better from it. Hopefully over the next few weeks/ months it will continue to help.

My hip had been consistently getting better and I seem to be having a set back at the moment. It is very hard for me to deal with this given my poor history with "issues" with this hip. When I had the prp injection the physiatrist commented that he thought some of my issues were partly a result of having Crohns disease and difficulty healing and being more prone to tendinitis.

A lot of the pain I had pre op has returned in the last week or 2. I am also having a ton of clicking and clunking, same as I had before this surgery. I'm not sure what is going on but I am extremely unhappy with this. I am tired if being in pain and this has become unbearable at times. My OS told me to give it 6-9 months before things are fully healed. I return to PT this week and hopefully it will bring me back to where I was before.

PRP Injection to Hamsring

Unfortunately, PRP is considered experimental by most insurance companies. As my OS office was trying to get pre certification for the injection, it kept getting denied. I urged them to try different codes but to no avail. They thought the problem may be partly the facility I wanted to have it done at, in the end we decided it would be better to have it done as an office procedure with another doctor. I forgot to mention that all of this took place in person, not over the phone, since I was getting nowhere trying to do this over the phone.

My OS office took care of canceling my first appointment and I went to schedule with the new doctor. Lo and behold he had an opening for 30 minutes later. I jumped on it!

I quickly went to grab a bite to eat so that I wouldn't pass out when they took my blood. It's a good thing I did because they took ALOT of blood and with a HUGE needle. The fellow came in to talk to me first, she was actually able to find the painful spot and reproduce the pain, no one has ever been able to do that before. As she found the spot she said " yep, you def have tendinosis".

When the doctor came in he also felt around for the spot and did a ultrasound to see where he would be injecting. He started injecting and took multiple passes at the tendon, it seemed like the needle was in me forever, and it was really really painful. I think it was worse than my psoas injection 5 years ago and that was bad.

His instructions were to do nothing for 2 weeks and then come to see him. I got home and the pain was intense. I ended up needing a lot if ice and a lot of Percocet last night.

My Ass Hurts

After 5 surgeries and years of on again off again pain I reached my breaking point. I am having so much pain at my ischial tuberosity that I am on the verge of a nervous breakdown. I've never gotten to this point but the pain has just worn me down and I'm becoming depressed, moody, and just unpleasant to be around. I emailed my OS last week and by Tuesday I hadn't heard back. My pre-op MRI stated that I have hamstring tendinosis and a tear, this fits my symptoms which is ass pain, specifically at the ischial tuberosity and pain with sitting. I was at PT which is about 50' from his office on Tuesday morning. I had tears in my eyes from the pain and downright frustration. I turned to my PT and said that I will give up my treatment time with him and I need him to go speak to my OS bc I can't take this anymore. I said tell him I need something Now. My preference is cortisone but I'll take what I can get. He quickly returned and said that my OS said I should do a PRP injection into the hamstring. They have had athletes who have had great success with this. So I am in the process of deciding who to have do it. The radiologist who has done all my other injections is looking into it for me, he needs to be able to get the PRP equipment. I called 2 physiatrists that my OS recommended in the meantime just to have something set up in case my radiologist can't do it. They want $1250. Upfront. Gulp!!! I really have no choice at this point bc I can't continue to not be able to sit comfortably.

On a positive note, I saw my shoulder OS and he is thrilled with how things look. I don't need to see him again, he said you don't have to keep coming back to tell me things are great! He told me to be careful for the next month bc it is still healing but after that no restrictions!

9 weeks postop

I have once again gone missing for a while. In my defense, I've had a rough few weeks which included at one point using a crutch and sling simultaneously! I will be 9 weeks out tomorrow from the hip surgery. I am making slow improvements each week, getting stronger and gaining endurance. My biggest and only complaint is that I still have butt pain. It is pain right at the ischial tuberosity that hurts the most with sitting. It also comes in with too much activity but nothing compares to the sitting pain. I am extremely frustrated by this and not sure what to do for it, what is causing it and what can be done to make it go away. I know my hamstring is torn but I can't imagine that I would have pain his intense for this long.
My shoulder could not be a smoother recovery. I did have a small issue in the beginning when my hand was going numb. I stopped using my sling which helped and it hasn't happened at all in a few days. The pain I have is isolated to the clavicle, nothing else hurts at all. Today I was able to use my over the range microwave with my operated arm! If only my hip would improve this quickly!

I am not back at work but plan on returning in 3 weeks, 3 days per week. I used to see patients on my off days but I won't be doing that for a while. What I find very hard is that I fatigue very quickly. My body obviously took a beating, twice, and I can't expect to recover from surgery like I did when I was 26 and had a simple scope. I will try to write more often and if there are any major breakthroughs with my ass pain I will definitely post!

6 Days Out From Shoulder Surgery

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

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

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."