(Pre-pre-op) Hip pain: arthritis, bursitis or something more ominous?

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Dulcimer Diva

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2.5 years post-RTKR and 1.5 yrs post-LTKR, I was doing great (with a slight setback from a torn L upper gastroc after overdoing hiking in the Rockies), right up past New Year’s Day 2015. Late in the first week of Jan. we had our first accumulating snow of the year, so I decided to be conscientious and shovel as best I could. (Unshoveled sidewalks had always been a bone of contention for me whenever I was temporarily disabled after orthopedic surgery, and I didn’t want to be “that” heartless negligent homeowner). All seemed well until a day or so after a particularly strenuous shoveling and ice-chopping session, when I began getting pain in the general area of my R hip upon getting up from first a recliner, then any chair or toilet. The pain didn’t occur when sitting, standing, or lying on my back or other hip--just on walking, especially ascending (but not descending) stairs--just the opposite of when I had arthritic knees.

At first, I figured it was just a strain. I kept up my maintenance doses of acetaminophen (2 x 500 at bedtime, 2 x 650 “arthritis formula”) and 200 mg. celecoxib on arising, prescribed for the gastroc tear (and successful in healing it). Tried icing and heat to no avail. By the end of the month it had worsened to the point where it would hurt getting out of bed and even sometimes when lying on that side. Went to my FP, who manipulated my leg, poked, prodded, and had me step up with my R leg. He said it’s not arthritis but rather trochanteric bursitis. He said to continue the same pain meds (would have preferred I take naproxen but acknowledges it aggravated my GERD and even caused a small gastric bleed last year). He also prescribed Lidoderm and Flector patches with Voltaren and arnica gels and menthol rollers if they give relief. He also said that since it’s not arthritis there’s no need to expose myself to the radiation from an X-ray, nor the expense of an MRI (tricky with all the hardware in my legs).

Well, it’s been getting worse. The pain on weightbearing motion is so diffuse (radiating to groin and down my thigh, sometimes even to and below the knee) it’s difficult to pinpoint whether it’s coming from my trochanteric bursa or from the joint itself. A little background--back in ’96 I was hit by a car, which shattered my R tibial plateau. Ancillary to the open reduction-internal fixation surgery, my then-OS harvested bone from my R iliac wing to mix with epoxy to form a stable matrix in which to implant hardware in my tibia (which remains to this day, minus the top 2 screws and rod portion that had to be removed for the TKR). In 2004 after a rapid but intentional weight loss, I experienced painful snapping and catching in my R hip, relieved only by swinging my leg (and temporarily at that). My successor OS (who’d been the tibia-surgeon’s partner at a different office before it split into two groups) discovered on X-ray that the top horn of my iliac crest had actually snapped off and was floating free--causing a tendon or ligament to catch on it. After putting me through a nuclear scan to rule out osteosarcoma (I was too young then for osteoporosis to have been a cause), which turned out to be negative for anything but inflammation, he opined that his ex-partner may have harvested an excessive amount of bone for the ’96 graft, which ultimately weakened the iliac wing causing the fracture--and until the weight loss, my fat was holding the broken-off piece in place. He advised watching and waiting to see if the piece would resorb, and it apparently did.

So I’m wondering if what I’m suffering, if not bursitis, is either referred pain from arthritis, further degeneration of the iliac wing, or--more ominously--either necrosis or heaven forbid, a tumor. Should I demand an X-ray and/or MRI? I’m using a cane now, which helps only partially. (After being on my feet for a little while, the pain isn’t so bad, but it does re-intensify after half an hour or so, such as when shopping). Complicating matters is that I have a weeklong trip to Las Vegas coming up this Thurs. We got a good deal on first class airfare and thus don’t need exit row seats, so I can use a wheelchair in the airport and openly carry my cane. But walking distances in Vegas are huge--my husband says he’s willing to push me in a wheelchair the whole time (I joked that I should rent a scooter, in order to blend in with all the other sixtysomething Midwestern female tourists--but then I’d need a fanny pack, ugly T-shirt, shorts, baseball cap and giant plastic cup full of quarters to complete the ensemble). And I have a continuing legal ed trip to Spain (Madrid, Barcelona, Seville) coming up in early April--traveling alone to boot. (Husband let me spring for business class air, though between cities in Spain there’s just coach or rail).

What would you do? Further complicating matters is that my wonderful OS Dr. Wixson has retired. I can get into the walk-in clinic at North Shore Ortho in Skokie tomorrow.
 
Two years ago I was shopping prior to a trip to Ireland. The muscles on the outside of my left hip cramped in such a fashion that I could not walk. All I could do was limp to a shoe store and sit for awhile until the aim eased up. I knew this hip was arthritic but it had been staged as moderate when last checked. However, the cramping was an entirely new feature. I did not want to take a chance with overseas travel (long lines coming and going through customs, transporting luggage, lots of walking, etc.,etc.) so I made an appointment with my Personal Physician who referred me for a hip x-ray. It turned out that my hip had progressed from moderate osteoarthritis to severe osteoarthritis so my Personal Physician referred me to an OS for evaluation and discussion. He told me that I would need a THR but that I would know when the time was right. I asked him about the planned trip to Ireland and he didn't see a problem with it. He gave me a couple of prescriptions to combat any pain or any "events" and recommended that I take a cane. I took the trip and got along o.k. although I could not walk as much as I would have liked. My husband was there to deal with our luggage so that wasn't an issue for me. All of this is to say that if I were in your shoes I would try to find out what was happening (yes to the x-rays) and be thinking about ways to handle solo overseas travel.
 
If this was my situation I would get that hip x-rayed or scan ASAP. The sooner you get a diagnosis the better. You have lots of history but this sounds like the pain I had pre LTHR. I waited far too long and the hip collapsed.
 
Sandy,
I agree with Jaycey, you need a diagnosis, the sooner the better. At least you will know what you are dealing with, for bursitis they can inject steroids if what you have been doing is not working, as they can do for your hip.
Glad to see you back, wish it was better circumstances.
Keep us posted on what they say,
 
Feeling a bit better--and unfortunately, I overslept and missed the NOI Skokie walk-in (hobble-in?) clinic. Wonder if the Immediate Care clinic around the corner can take an X-ray or do a cortisone shot to the bursa--if the latter works, it’s further confirmation of no hip joint OA. (frankly, I’m more concerned about further iliac wing fracture or necrotic changes). Two physicians (my OS twice, once in Jan. 2013 and now my FP) were sure that I did not have anything going on in the joint itself. But if it turns out I do need a RTHR, I guess that takes care of how I’ll be spending June & July. (Too much booked for May).
 
Sandy,

I was just reading your thread when my friend called, she is a physician, she has been having a lot of hip pain, she wanted the phone number of my wonderful OS at NYU, she is going in to see him to have an x-ray and get a proper diagnosis, then schedule surgery on her right hip (she is pretty sure she needs a replacement, but she wants an expert to look at her range of motion and an x-ray).

Why do I mention this? I would see someone who is a specialist. You've been through a lot, so you know what you might be facing, which is unpleasant, but an x-ray and an exam will tell an OS or a rheumatologist what's wrong. I had a trip planned before my first THR, so I did get a cortisone shot to ease the pain, but it did not last long. Whatever they find, good luck. Read my threads, links below, I am eight months from my RTHR, 28 months from the LTHR, and doing exceptionally well. There is life after THR.

Mark
 
Good news--though there's a little mild arthritis in my hip, it's not enough to cause any symptoms yet for at least a few years. No neoplasms, no further fracturing of the iliac wing. But one big honkin' bursa--plus IT band and both gluteus minimus and medius irritation. The bursitis was almost certainly caused by overdoing shoveling and the rest probably from slogging 1/4 mi. each way through a foot and a half of snow over undulating icy terrain during the Super Bowl blizzard--in UGGs a size too big and using trekking poles. Had a massive cortisone shot (needed ultrasound to guide the giant needle) and have 6 wks of PT 3x week. I see a lot of bridges, stretches and clamshells in my future.
Moral of the story--no Super Bowl party is worth hiking through a blizzard; and if I can't find someone else to shovel snow I should just pay the stupid $50 ticket! So tomorrow I have to spend all afternoon at the therapy gym, plus twice a day in the hotel gym in Vegas. (Finishing up the croissant and cappuccino I gave myself as a consolation present after the clinic and standing in line to vote in today's Mayoral coronation....uh, election)
 
Congrats! While the shot and the PT are no picnic, they are MUCH better than THR.
 
But one big honkin' bursa--plus IT band and both gluteus minimus and medius irritation.
Just what I was about to say!
Had a massive cortisone shot
Jolly good - that's the very best treatment for a TB.
have 6 wks of PT 3x week. I see a lot of bridges, stretches and clamshells in my future.
NO! Do not do any of those things for your inflammatory condition. It will make it worse, I promise you. And bridges and clamshells are the worst, very punishing on those structures.

You only need to do stretches and see a chiropractor to get some good deep acupressure massage. I have suffered from those conditions for ages - first in the right leg and more recently my left. I have had the massage from my chiropractor and it is nearly all better now. (No exercises nor even stretches!)

For the stretches, read this ITB (ilio-tibial band) issues and treatments.
Here is an article about Trochanteric bursitis but there are no stretches (or exercises) to treat this. Only the cortisone.
 
I have an excellent chiro who is also a naprapath, and 19 yrs. ago he cured a severe iliopsoas strain in two sessions of deep tissue massage. I will see him upon my return. Can probably use a new set of orthotics anyway. I am much better this morning. I found out from my patient discharge summary that in between the lido and cortisone shots two syringes full of fluid were drained from the bursa (3”!). I now have a tiny bruise, which aids me in placing the pain patch. The OS also has me doubling up on my celecoxib (2 x200) the next two mornings as a loading dose. I will avail myself of wheelchairs in the airports and bring my cane anyway. No point in trying to be a trouper, as there isn’t a show or team depending on me right now.

I am not sure if PT will consist of anything more than massages and ultrasound. If it does, I will air my (and your) concerns to the therapist before I proceed. The OS who saw me yesterday is a sportsmedicine specialist, as is his PA, so perhaps they figured I was somewhat athletic. When one is a hammer, everything looks like a nail....
 
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I just read your post about PT, and wanted to pass on that I had a cortisone shot to my hip joint (not the bursa) last July, and was also advised by the physiatrist to go to PT after about 4 weeks of having my pain resolved. I did, I was assigned alternating heat and ice, and then stretches and 20 reps 3 times a day of 3 different exercises (180 reps in total) of what I thought were dinky little exercises (moving my leg out to the right 20 times, backwards and forwards 20 times each, really, NOTHING type exercises).

This was supposed to help strengthen my hip muscles BUT within 2 days I was suffering extreme, excruciating pain. Turns out I should never have used heat (only ice for a long term hip condition) and the excessive movement in my hip seems to have either allowed or caused or perhaps accelerated some of the tip of my femur to deteriorate very quickly (I did have moderate arthritis, which by December turned into rapidly progressing arthritis). And I regularly went to the gym 2-3 times a week for weight training and/or spinning classes for years, so I am not unfamiliar with exercise.

Now I am going in for a total hip replacement on 3/24. I am only telling you this because I too have had several shots for bursitis in my hip over the past years, and was told to NEVER have PT on/around the bursa area, but rather was told to leave the bursa alone (other than ice) so the inflammation could have a chance to decrease. Also ultrasound heats up the area, which I was told was not good for long term bursa issues (ice is OK). This worked well for me, but I must say the PT that I later did for my hip joint did NOT work out as well.

I know my story is merely anecdotal and not scientific, and my sudden deterioration could have nothing to do with the excessive movement from those hip PT exercises, but I really would pay particular attention to what Josephine just posted, my situation leads me to think what she says is absolutely correct.

And btw, if something happens in the future that leads you to think that you may have necrosis or a tumor or a bone infection etc., you MUST get it checked out immediately with an X-ray and/or an MRI, waiting does nothing but harm!! Good luck!!!
 
Thanks. Spoke to the PT this afternoon and told her that I’d been warned about exercising for bursitis; and that I would call for a consultation upon my return from Vegas next Friday. Right now I am experiencing a little soreness right at the injection site, but no swelling, redness or heat--and certainly not limping like I did before my OS visit yesterday. I wore a Lidoderm patch over the bruise and it did not hurt at all; but the lidocaine in the patch wore off after 12 hrs. and the directions say “12 hrs. on, 12 hrs. off” so I switched to a Flector patch, which is nowhere nearly as effective. I will use the Lidoderm while in transit, as well as when I need to walk some distances. Icing is helping somewhat, too.

What I’m wondering is if there’s any treatment for the IT band and glutes that doesn’t irritate the bursa. After reading the article and viewing the illustration, I realize that the IT band was probably the connective tissue (or one of the structures) that was “snapping” on the jagged edge of my iliac wing back in 2004. It’s not hurting me near the knee, which is its classic presentation as an overuse injury in athletes.
 
So glad things are better. I have very painful IT bands on both legs (but not because of iliac wing issues so can't comment on that). The best thing I have found for "releasing" them, below and up to the the hip area, is a "Tiger Tail" which I have also used on my glutes, quads and hamstrings: http://www.tigertailusa.com/ If I use it regularly I feel virtually no pain in the IT bands, but I have to keep using it every day as they tighten right back up again without consistency. It also feels so good on muscles, but don't go too deep too fast. I would think regular massages (avoiding the bursa area of course) would help, I just can't have them every day, but I can use the Tiger Tail every day and when I do after about 10-14 days I have no pain at all. It is just a temporary fix, but IT stretches don't even reach the IT band as I am double jointed. P.S. Any chance that snapping noise was a labral tear? Just curious!
 
It wasn’t a snapping noise, but a “catching” sensation, relieved by swinging my leg...until it was no longer relieved. (My then-OS, after visualizing the fracture on X-ray and ruling out cancer via nuclear bone scan, was able to gently manipulate the hip into proper position, and the broken-off piece of bone eventually resorbed--there was no sign of it on yesterday’s X-ray, just the healed edge of the iliac wing that was shorter than its counterpart). Had there been a labral tear, it would probably have been sudden in onset with pain at rest and swelling, rather than just on weightbearing and motion--and it’d have lasted more than the 10 days-2 weeks it persisted.
 
Yes, a labral tear feels like a catching sensation and doesn't make a snapping noise, it is just called a snapping hip, but lasts for far longer that 2 weeks - try 2 years! Sounds like you know your body very well, good luck in Vegas etc.
 
I’ve noticed that Flector patches don’t work nearly as well as Voltaren gel but the Voltaren gel lasts less than an hour. Lidoderm patches work MUCH better than Flector. Flector can be worn 24/7 so long as it’s changed every 12 hrs. but the directions on the Lidoderm say up to 3 patches at a time 12 hr. on, 12 off. I looked it up and found that there can be serious side effects of a full dose of lidocaine for 24 hrs. But I only use half a patch over the bursa. Can I wear half a Lidoderm 24/7 so long as I change out the half-patch every 24 hr? Worst comes to worst, I can save the Flector for sleep (plus 2 hrs. either side) and then the Lidoderm during waking hours. But the sleep I got last night wearing the Lidoderm was the best I’ve had in weeks--and no pain at all going to the loo at night and then getting back to bed. This afternoon, when I switched to Flector, the pain started to come back (though I wasn’t limping and hobbling as badly as before the shot).
 
The pain on walking now is nearly as bad as before the cortisone shot--and unlike before, no amount of walking is helping. (I hope that what I need now is not "no amount of walking"--two days left in Vegas, and we've had to take a lot of cabs for distances I walked easily in September). It's not excruciating but very, very sore nonetheless--the injection site pain should have worn off by now. Found out too late about 702scooters.com--seems many people are renting them here (even some able bodied millennials who were holding scooter races in front of Planet Hollywood yesterday). I am insisting on a wheelchair for the airports en route home Thursday.

The orthopedist who gave me the shot was unable to visualize the needle on the ultrasound screen, only the bursa and the motion of the surrounding tissues--he remarked aloud about this. Should I be worried? And the x-ray report mentioned "cortical neck prominence seen in patients with femoroacetabular impingement" but did not mention seeing anything else except "mild degenerative changes" and that the "acetabulum was fully covered" but that osteophytes were present. The osteophytes were obviously the mild degenerative changes, but should I be worried about the cortical neck prominence?
 
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