The saga continues...surgery next?
Argh. An update and some decisions I need to make and which
you all may have opinions on. To summarize my situation:
- In February of this year I had the onset of some right adductor
pain and some hip issue that limited training. I limited training and eventually
it got better although not totally better. Intermittent.
- In July it all returned, worse. I would have some minor
discomfort at the start of a run, then it would go away, then after the run I
would be in a lot of pain for a day or so. Any runs longer than about an hour
and I had a hip pain. Under an hour and I was ok except afterwards.
- A course of strong anti-inflammatories (oxaprozin) caused
me to be pain-free.
- An MRI and exam in early August yielded the following
diagnoses:
(i) stress fracture of the pelvis ("parasymphyseal
region of the right pubic bone"), but a "borderline call"…whatever
that means
(ii) impingement of the right hip (identified in clinical
exam)
(iii) evidence of a healed stress fracture on the other side
of the pelvis
- The doctor's recommendation was run "as
tolerated". I significantly limited run training – 20-25mpw and no runs
over an hour. No NSAID use during training. I did Ironman Wisconsin, the run
was poor due to lack of training but no pain. I used NSAIDs during the race.
- After IMWI I did no workouts for 2 weeks. Since then I resumed
biking 3-4x/week, max workouts 75' but most of them 60'. No running since Sept
13.
- As of today…(a) pelvis discomfort totally gone, (b) adductor
discomfort intermittent (some days better than others with no apparent link to
anything specific I am doing), (c) hip pain continues worsening and it
is uncomfortable to be walking around – not debilitating pain but I
can feel it all the time when walking.
- Between October and now I went to an orthopedic doctor at
Rush named Dr Mjannes (previously I was seeing a general sports-med doc who is
a DO). To make a long story short, after a follow-up appointment where nothing was
getting better he ordered an MRI "arthrogram" and referred me to a
colleague who is a hip specialist (Dr Shane Nho).
- I had the arthrogram on Thursday and the appointment with
Dr Nho yesterday (Friday). I do not have the radiologist's report but Dr Nho read
all of the images in advance of the appointment, did a physical exam and
concluded:
(i) Bone edema still in the pelvis but stress fracture
cannot be seen. Apparently the edema can take a long time to go away after a
stress fracture heals. No symptoms. Conclusion: stress fracture fully healed.
(ii) Adductor "lit up" on MRI at the point near
where it is attached to the pelvis. Conclusion: tendonitis.
(iii) Cam-type impingement of the hip. Very significant
deformity per MRI and an October x-ray taken by the other doctor. "Very
good joint spacing", indicative of lots of cartilage. Labrum frayed but
doesn't look torn. The cam is on both sides per x-ray (arthrogram was only on
the right) but no symptoms on the left. Clinical exam indicated very significant
impingement symptoms on the right.
- The surgical option is a "scope" that will
address the impingement. During that procedure he would assess the cartilage
and address any issues there (incl microfracturing if there are major areas of cartilage
missing). The labrum could be addressed as well but he doubted any problems
since it didn't look torn. Recovery is pretty major…4 weeks on crutches,
several months to recover fully. Naturally no assurance of success and there
are risks of complications, but apparently this procedure is very routine.
Internet research says in 85% of cases the patients get fully recovered and back
to their prior activity. In 5% of cases they are worse off.
- The other option may be intensive physiotherapy. This will
not address the bone deformity but might address the symptoms. I am going to
meet with a physiotherapist to investigate this possibility. The doctors are skeptical
that will work based on the degree of the cam and development of my symptoms.
- I am seeing another doctor based out of a different hospital
on November 23rd for a second opinion (Dr Patrick Birmingham at Northwestern).
However, he is a specialized hip surgeon so may be biased to a surgical option.
Overall I would prefer to avoid surgery given the risks and
extensive recovery. However, the reality is that this injury has been
problematic for almost a year and is still getting worse despite no running in
2 months. I have already written off 2016 as far as endurance sports are
concerned and honestly I'm fine with that. But wasting 2 months trying something
that is unlikely to work then having to do the surgery in the spring is very unattractive…not
only does it have me limping through whatever family summer stuff we'll cook
up, but also the upcoming holidays provide great cover for me work-wise while I
recover (many of you know my job has me on an airplane 4-5x/week).
So that is the update. Some more information to come with
the second opinion. If anyone has comments or suggestions or even wild theories
feel free to throw them into the mix. Anyone who wants to read the latest MRI
feel free – the below link will work for the next 4 days after which shoot me a
note and I'll send you a fresh link.
Cheers,
Matt
Comments
I am an Orthopedic Sports Med physician. Total disclosure : I trained at a center that was an early pioneer in hip arthroscopy and have done many of them but do not do them in my private practice.
The diagnosis of Cam acetabular impingement is a well-known problem and typically affects athletes (like you). My review of the MRI confirms the diagnosis based on the images. The only reason to have surgery is if you are symptomatic (and you are) and you have failed other management options (which you have). As far as the surgery goes, ask the difficult question : how many hip arthroscopies does your doctor do in a year? How many cases of hip impingement has he scoped? If he hasn't done in the 100's overall and more than 20-25 per year, consider going to someone who has and does.
I think that you may be surprised about the speed of your recovery. You will be able to swim almost immediately so consider working on that early, they will probably let you start back on the bike pretty soon too so you might not be out as long as you think. I think that it would be perfectly reasonable to have it done sooner rather than later. Best of luck.
As you know, I have been dealing with a high hamstring tear since end of 2013. Finally went to Dr April 2014 and started rehab, no luck and I one could really tell me what the issue was. Drove 3 hours to UPMC to get a recommended opinion and he said within 2 minutes, it's torn and need surgery as it will never heal. I am personally very nervous about jumping into things that serious to quickly so decided to get another reference at Cleveland clinic. The surgeon there said it was a borderline case and he wouldn't jump to surgery right away. Mental dilemma as I have two very different opinions from very good hospitals.
In the end, I didn't do surgery and tried alternative rehab options (physio, PRP, Shockwaves) and completed Madison with you successfully. Today (knock on wood) still no pain (in hamstring at least..think something else is brewing but different post.)
Alternative story is that my sister just went through surgery for Labral tear of the hip. Personally I would not have rushed into that as quick as she did however now 3 months on (she is very fit), she is swimming and elliptical.more cardio is soon.
Matt...reason for "my saga" is perhaps to make you think about options. I personally would get 2-3 opinions on your scans before doing anything. Nothing against surgeons however I think some just like to cut and you have to be careful. I tent to err on the side of try everything before you go under the knife. If you think you have done that, and got the best opinions out there, then maybe surgery is the right choice but only you can decide.
If in the end you decide yes....I agree with Ralph that considering your fitness, you could find recovery to be pretty straight forward (as my sister did).
Let me know your thoughts and decisions...either way I am sure you will take the right choice as you are the best judge of how you feel.
Again, my 2 cents but hope it helps.
Matt - Preface: I have no clinical or professional expertise in this area, so my comments are purely as a friend and fellow athlete. Also, colored by being now 48 hours post-op from surgery myself.
The way I look at your problem:
My only worry is your work. Over the years, I saw so many high-performance people who figured when I said, "You are going to feel tired and low energy for at least 4-6 weeks after the surgery. Your body will be spending a lot of its energy repairing itself, and will need extra rest both physically and mentally", that it didn't apply to *them*. That they would be able to get back to managing people no problem within two weeks. "If I can walk, I can work". Don't be That Guy, especially if you want to get back to your previous level of professional and athletic performance. (This is a caution to myself in my current situation, as well as to you.)
I've never heard of a labrum thing-a-majig until this year. Apparently that can end a running career if torn so I would want to make sure that whatever is causing the fraying is addressed. Best of luck!!!
Hey Matt...I've been meaning to catch up with you, and see how thins were going. I guess not so good. Really sorry man.
Here is my 2 cents. You've rested for 2 months now, which is an eternity for you, and it still is bothering you. You could do the PT and that might help but will take more time and no guarantee. While it is easy for me to say this, I'd seriously consider the surgery. If you are going to be out training for a while, I know you want some rate of return on the down time. So I'd go with the thing that has the best chance, highest probability of success of getting you well again. Whatever you decide, I know it will be well thought out, and the best for you and your family.
When are we getting together for our yearend dinner? I'd love to do that again.
You need to find your own path, but what Al says does make some sense to me. I think you're wise to get 2-3 opinions. These chronic things seem to be the hardest to properly diagnose and deal with. As long as you're set for taking the long time to recover, I'd be tempted to go with the surest bet, regardless of the total time of recovery.
A few responses and updates, and a few additional thoughts and questions…perhaps mostly for my own benefit, so I have this all on one place when I prepare for the appointments to get the "second opinions" and need to make sure I don't forget any questions. Btw you may notice I pluralized the second opinions. I am also seeing (in addition to a PT) a sports med doctor recommended to me by our own teammate David Salzman. He is not a surgeon so may not have so much surgery bias.
@ Ralph, totally understand on the experience issue…the two top hip doctors in Chicago are Dr Nho and a guy named Dr Terry who I couldn't get into see in time. I will get the number of procedures, that is good to ensure I have.
Now for the new information. I have finally received the radiologist's report. It contains a number of things that I do not understand and may conflict with what I heard in the appointment although, again, the language in the report is very technical so I don't really know. Obviously I will have this for the second opinions. The key points in the report (in addition to the cam impingement that is once again clearly noted) appear to be:
1. "Equivocal small fissure in the superior anterior labrum…focal thickening of the chondral labral junction in the anterior superior labrum…otherwise, no other labral tear is noted". I don't know if this is the same as the "fraying" that the other doctors noted or if this is more significant.
2. In the part that describes the cam deformity it includes language: "Two tiny subchondral cysts are noted along the anterior femoral heads" and "There are tiny ossicles along the lateral aspect of the right acetabulum". No ideas if that is important.
3. In addition to the edema in the pubic bone, the report notes: "…a 4mm partial tear at the attachment of the obturator externus and adductor tendons at the pubic symphysis. There is a linear hyperintensity along the obturator externus muscle, concerning for partial tears in the obturator externus muscle." This is I think very important. I have been struggling with what have appeared previously to be "adductor issues" along this entire injury journey. It seems like there is some muscle tearing at the attachment and intramuscularly. Perhaps this needs treatment and won't go away on its own.
4. Finally, that %$#%# stress fracture…"A linear T1 hypotensity is noted in the right pubic bone", concluding "Stress fracture in the right pubic bone". So perhaps that is not in fact healed. After 2 months of no running...
And so it goes……..
https://send.bcg.com/Lgxwsh5euv0dBwTWW5jDFAhp
Not only is the answer "yes", but also if there is one constant refrain these doctors all say it is that the MRI is really to be taken with a grain of salt and that the symptoms are the main factor to guide the diagnosis. There are a few moves that all of them have done at one point in the exam where they say it is very classic (lying on back with knee up then they twist it and it causes pain).
The adductor thing has been going on in parallel for some time as well. But it is quite distinct from the pain in my hip. The adductor thing kind of ebbs and flows a bit. I need to get a better handle on that and will ask a lot more questions about that in the next appointment (currently scheduled for Nov 30).