THR Psoasis Relief

[Ptarmigan]

I have recently started Muscle Activation Techniques (MAT) therapy as prehab for my THR. I learned that feet have 54 joints apiece, and of those, only 15-20 of mine were neurologically responsive. The other 35-40 joints didn’t work. The muscles that controlled the 15-20 joints were doing all the work...and not very well it seems.

So, what happened when my feet joints turned back on? I regained one inch in lost height, from 5’2” on April 1 2019 to 5’3” on May 15, 2019. This is because I regained control of dozens of muscles that control posture and I could stand up straight again!

So, I have had valgus knees for as long as I can remember (knock knees). When I bend, my knee caps point 45 degrees in, and point over the inside of my big toes. Last week, in therapy, we started on hips and found some adductor/abductor variations that refused to respond to command. We did isometrics, nerve activation, and testing - repeat cycle many times - and then I tested my knees. They bent straight over my middle toes - it was completely unbelievable to me. My ROM dramatically improved in that hour - and I did not stretch.

I have to be very careful with new circuits though, because they can shut down from overuse, and muscles that have been offline for a long time need tender care, too.

I wish you all the best in your search for the active and healthy years you have been looking forward to!

 

[Horseshoe]

Hi @Jws. I recall your story from when I used to post here. I saw your choices and if it was me after 15 mos of pain, I'd make a beeline to HSS and consult with one or two *revisionist* surgeons. I wouldn't mention the release or what your original surgeon already said so they wouldn't be swayed

The hardware may be fine but it may be poorly placed, aligned, settled, protruding screw, offset, etc. A different set of trained eyes sees things differently from the original OS, have seen this scenario play out many times here to good results.

The link below is from @prairienut who had a very good experience with her revisionist OS at HSS.
@Going4fun has good input too, both researched OSs in depth and have a nice clear writing style.

(I note such OSs for my records for future use plus I keep meeting people who need thrs!)

Good luck.

https://bonesmart.org/forum/threads/a-new-year-and-new-hope-revision-for-loosened-thr.51890/

 

[Jws.]

@Josephine @SaraK @Horseshoe...And the hits just keep on coming with this hip nightmare... was coughing for two weeks..just got the xray results ...have "walking" pneumonia..(no fever,chills) just coughing and phlegm.

Is there anyway this gets into bloodstream and gets to hip?

I have been on amoxicillin week after the cough started, the next week upped antibs to cipro for 10 days and three days ago (after xray results confirmed pneumonia in lower left lobe) PC doc put me on zpac with the cipro for the last five days (including prednisone 5mg taper). Never had pneumonia before (tips as well here). Am I going to be recovering for weeks or months?

As an aside my groin pain is 80% better. I can raise my leg with very little pain, get in car with very little pain. My hipflexor "catching" pain is gone.

My point is this: is the prednisone (cortisone) as telling of a test marker for psoas impingement as a direct shot in the psoas.

It definitely feels all around much better but especially in the significant tell tale tests for psoas impingement, hip flexor catching (gone), lifting leg up (1-2) getting in and out of car (very little discomfort-1), putting pants on 1 as well). Does this confirm psoas impingement. even though it is oral cortisone and not direct shot in psoas???

Any thoughts please jump in! Would truly appreciate all opinions.

I can definitely tell you that I am feeling less depressed and much less all around joint pain.

I am definitely not looking forward to the cortisone wearing off and the nightmare of the groin pain and the limp, and the hip flexor "catching " pain from sitting to getting up coming back.

@Horseshoe do you have a list of the best revisionist at HSS..(Bryan Kelly - "gaga- Arod") would not see me, does not see patients that have a THR already . You indicated you had them stored for people you meet who may need them. I may need them.

Also as an aside do you have the names of the best arthroscopic post hip replacement docs at HSS as well. I would appreciate it. Thanks all again...

I thank you for your thoughts and help..

 

[Josephine]

Hi Jeffrey.

Is there anyway this gets into bloodstream and gets to hip?

Well since you are already on antibiotics, no. And I doubt it would anyway.

You've contradicted yourself here

telling of a test marker for psoas impingement as a direct shot in the psoas.

Does this confirm psoas impingement. even though it is oral cortisone and not direct shot in psoas???

In the first quote you said it was a direct shot into the psoas and in the second you said it was oral.
So which is it?

I would add that it's most likely you were prescribed oral prednisolone for your chest. Is this what you mean?

You see, the steroid shot is not prednisolone. It's a synthetic form of cortisone which you can read about here Cortisone shots: are they safe and is there a limit to how many?
And they do work very quickly but are much, much safer than prednisolone which is also stronger.

 

[SaraK]

When I was dealing with my first hip and searching for a diagnosis for the pain (the xrays and a very poor MRI didn't show anything), my primary sent me to a pain management specialist. We thought he was going to do a cortisone injection into the hip. Instead, after essentially no examination, he decided there was nothing wrong with the hip (based on the xray and MRI) and decided it was my back. He wanted to prescribe oral prednisone and follow it with an MRI of the spine. He told me that the oral prednisone would circulate in the entire body and take care of the inflammation, wherever it was.

I can't say what the actual result would have been. I am diabetic and had concerns about what an oral steroid would do to the blood sugar (he was very dismissive when I asked). My primary agreed that I shouldn't take that med and I never saw that pain management doctor again.

 

[Josephine]

Oh-ho! What a charlatan! I suspect he was making it up as he went along! But he was right in one thing - it is entirely possible that many of these issues are related to spinal problems.

 

[Jws.]

@Josephine @SaraK @Horseshoe ..last post a little convoluted...so this will clear it up...
Took the Prednisone (cortisone ) taper 5mg.. beginning last week and now for about 4 days...(for the "walking pneumonia)....as an aside it has worked wonderfully on my "psoas" pain...I did all the psoas pain challenges yesterday which gave me pain( 2-4) before taking the prednisone ...
1. NO GROIN PAIN (0-1) -(my major issue)
1. lifting leg into car...0-1 pain
2. Bending down to tie shoes and put shoes on No pain in groin (slight pain in back by posterior" scar)
3. more range of motion and walking (no pain)
4.putting pants on (without leaning on something) no groin pain (0-1)
My questions regarding the above are these: :

1: Can several consecutive treatments of this cortisone waiver...reduce the inflammation enough (which it apparently has done here to cure the psoas impingement without a psoas release just like a LUCKY "one and done " psoas shot directly into the spoas shot...or am I just "masking the pain like with oxycodone but after using the pain will come right back.
2. Could my psoas impingement be NOT as mechanical (not rubbing on the hip that much that a slight reduction in inflammation could take it away)
3. Could it not be psoas at all but a "general " inflammation that the cortisone has healed or brought down...Ie scar tissue, etc.
4. could it be the reduction of the inflammation by the cortisone and the comnination of the not doing PT or exercising during the 4 days of the pneumonia that have brought me this relief.

**** My ortho a MONTH BEFORE before this happened ( pneumonia) thought that he could get the same result if he would give me a series of 3- 4 cortisone shots into the psoas and at the same time attempt to stretch the psoas muscle and tendon with "aggressive PT". (he also said he would "bathe" the capsule with the cortisone during the shot to give me more range of motion as well.)

A month ago I took my first psoas shot with him as he suggested and had one day of semi relief (nothing as compared to the above relief with the "cortisone pill taper"). In addition I had some sucess with the agressive PT ( i believe ) as in 14 months I was unable to tie my shoes and I could finally do that after the pt.

Notwithstanding...the relief of the aggressive Pt cost me three days of groin pain after some sessions and no relief later on with any of the challenges listed above in the pill taper.

@Josephine . and others , Please give me your thoughts on the above....As you know from my posts I have been looking for OS's who do psoas release and was pretty well set on getting one because I was despondent as hell and in 14 months post op I have not one pain free day... I have even (against my better judgment i.e significant more serious complications, infection,dislocation,??? ) now considering a total revision..

In light of the relief of the cortisone pill taper..I feel there should be ( hope and pray) an easier less draconian solution than a complete revision or even a Psoas release///

Thoghts from all are welcome...thanks as always....Jeffrey

 

[Horseshoe]

Hi @Jws. Glad you are getting some relief ! Continuous pain is a real mood deflating experience. Maybe being sedentary from the illness has also helped?

Fwiw, I moderated my former workout, now take days off, and have eliminated some movements that annoy the IT band. Figure it's part and parcel of having two fake hips. BS often warns about PT and overdoing the exercise and I completely agree in my case.

For HSS, drs mentioned here with good feedback are Bradford Waddell, Thomas Sculco (is retiring, his son Peter, is also an OS). There's a search bar on HSS website, type is Hip revision and you can go thru the list, read their bios.

Sometimes these in-demand surgeons will review your sent-in xray (for a fee)

Jaime here on BS is very helpful in finding an OS too. On BS you can read some of the revision threads for clues and can type in HSS in the BS search bar.

 

[Josephine]

1: Can several consecutive treatments of this cortisone waiver...reduce the inflammation enough (which it apparently has done here to cure the psoas impingement without a psoas release

Yes, of course it can.

2. Could my psoas impingement be NOT as mechanical

Of course

3. Could it not be psoas at all but a "general " inflammation that the cortisone has healed or brought down...Ie scar tissue, etc.

of course

4. could it be the reduction of the inflammation by the cortisone and the combination of the not doing PT or exercising during the 4 days of the pneumonia that have brought me this relief.

Very likely

nothing as compared to the above relief with the "cortisone pill taper"

Don't confuse or mix the Methylprednisolone (injectable steroid) with the oral prednisolone. They are two completely different medications although they do have similar effects.

I have even (against my better judgment i.e significant more serious complications, infection,dislocation,??? ) now considering a total revision..

YOU are considering it? Has a surgeon told you this?

Jeffrey, I really though we had discussed all this at length previously. Did we not?

 

[Jws.]

@Josephine Jo, I thought when we had talked in our discussion (prior to this new oral prednisone development - which you indicate now could actually cure or relieve most of my pain in a couple of treatments)... about the following..

You mentioned that given the consistent pain and no clear resolution, that I should at least consider seeing a revision surgeon.

Of course, this would only be after "little guns first", trying out the physio (non aggressive) with couple of cortisone shots, than trying psoas release than as a last resort revision. I think that is still true correct?

Regarding the prednisone pill development, would I do a couple of two week treatments and hope for permanent relief or would this be a remedial treatment of prednisone for pain like celebrex as needed..

As you know, I am not looking for pain relief and to be on and off of prednisone forever (like the use of celebrex or advil) but a permanent resolution.

Thanks Jo for responding so quickly

** to answer your last question... no, a surgeon hasn't recommended a revision as of yet, they all generally agree psoas release first!.

 

[Josephine]

prior to this new oral prednisone development - which you indicate now could actually cure or relieve most of my pain in a couple of treatments

I did? I don't recall saying anything like that. Personally, I would shy away from taking prednisolone because of its side effects, such as AVN!

Regarding the prednisone pill development, would I do a couple of two week treatments and hope for permanent relief or would this be a remedial treatment of prednisone for pain like celebrex as needed..

Lacking a crystal ball, I'm afraid I cannot comment!

You mentioned that given the consistent pain and no clear resolution, that I should at least consider seeing a revision surgeon.

Correct

Of course, this would only be after "little guns first", trying out the physio (non aggressive) with couple of cortisone shots, than trying psoas release than as a last resort revision. I think that is still true correct?

I'm a little puzzled by this comment. Did you mean that word to be 'than' or 'then' as 'then' changes the whole concept of your comment. Which was it?

to answer your last question... no, a surgeon hasn't recommended a revision as of yet, they all generally agree psoas release first!.

I'd agree with that too.

 

[Jws.]

Josephine, SaraK, Harryn1

Jo, this is where I understood that you thought there was a possibility that the "prednisone regimen" could "possibly " cure the psoas impingement from my last post...
My question to you:
1: Can several consecutive treatments of this cortisone waiver...reduce the inflammation enough (which it apparently has done here to cure the psoas impingement without a psoas release

Your answer to me:
(Yes, of course it can.)

I see the confusion here , I said in that post "cortisone waiver" not "prednisone regimen"....sorry..


I saw my Os today and like you he said ..it's unlikely that two regimens of prednisone taper will permanently resolve the impingement...but "stranger things have happened" (I guess he was being supportive. )

He is an old school " open" surgeon and does nothing with arthroscopic surgery so it is difficult asking him about keyhole psoas releases. I did ask him about my two biggest concerns regarding the "partial" psoas release.

My two concerns are 1. risk of dislocation and 2. weakness in the operative leg

Regarding the dislocation, his response that he has never seen a dislocation caused by a psoas release in the lesser trochanter where in fact he had done all his "open" releases and never had a dislocation.

I pointed out to him that the new arthroscopic procedures are generally done by a cut in the central compartment.

He said that in that area , since you are in the hip cavity and it seems to him there would be a risk of dislocation but then qualified that by saying since he doesn't know the arthroscopic procedure done he couldn't predict or comment. He however, did finish by saying, even so "why would they risk cutting in that area when there is absolutely no dislocation risk in the lower trochanter.

My understanding of why they do the cut now in the central compartment is because of the tendon/muscle arrangement in the compartment and there is less muscle cut when doing the nick there and thus less weakness deficit in the operative leg..(I think I have that right)

So that brings me to my other concern the weakness deficit from the partial psoas release. As I discussed above , my belief from my research is that most "scoped" partial psoas releases are now are done in the central compartment (not all but the trend is there)

My question if anyone knows is, I am assuming that you will have a slight more weakness in the leg cutting the nick in the lower trochanter from the research, maybe 10% more but if you are not a ballet dancer or a competitive athlete, for ordinary living, walking,riding bike, getting in car, etc. it won't make that much of a difference.

I would appreciate any info on this
a. Is there truly more of a risk of dislocation doing the partial psoas release higher up in the central compartment?
b. is the weakness figures about right regarding the lesser trochanter (10% more weakness) but no real risk of dislocation in that area?

Thanks for the help....you guys are great...

 

[SaraK]

I would think those are questions for an OS that does psoas release. There must be a reason why they're doing it in the central compartment now and since my OS said there was less weakness doing it there, so I assumed it would be significant. I would assume there's a reason for the trend.

 

[Josephine]

1: Can several consecutive treatments of this cortisone waiver...reduce the inflammation enough
Your answer to me: (Yes, of course it can.)

I was referring to the synthetic cortisone also known as 'intra-articular' cortisone.

Regarding the dislocation, his response that he has never seen a dislocation caused by a psoas release in the lesser trochanter

I already told you this - neither have I. Not seen it nor even heard of it.

My question if anyone knows is, I am assuming that you will have a slight more weakness in the leg cutting the nick in the lower trochanter from the research, maybe 10% more but ... it won't make that much of a difference.

I thought I had explained that the psoas is not the only muscle governing this. See the image below.

a. Is there truly more of a risk of dislocation doing the partial psoas release higher up in the central compartment?

No, more than in anywhere else which is, at the most, minimal.

b. is the weakness figures about right regarding the lesser trochanter (10% more weakness) but no real risk of dislocation in that area?

Check out this image. There are at least 4 other, very large muscles that are responsible for this.

 

[Jws.]

Josephine, SaraK, Harryn1, fiveboysma, Small1014, nay502, Marvy, Mojo333

I think I decided to go forward with the psoas release. Anyone who has been recommended to, had surgery with , or knows of a good orthopedic doc who does psoas releases anywhere in the US, please post a reply to me. ALL HELP IS WANTED.

I have thoroughly researched the psoas release and have especially researched the advantages and disadvantages of a release at the central compartment versus a release at the lesser trochanter. Will post later.

Anyone who has had or looked into or had a psoas release, please give me your feedback on the pros and cons of each of the releases (central compartment or lesser trochanter) that you have found.

As always, thanks again..best jeffrey

 

[Jws.]

Josephine, Harryn1, SaraK, fiveboys, mary, slinky

My list of advantages and disadvantages of central compartment and lesser trochanter release

Lesser Trochanter
Advantages
1. Less Risk of Infection ( Not close to Hip capsule-no capsular penetration) 2. Less Risk of Dislocation (not close to Hip capsule-no capsular penetration)
3. no extended rehab (i.e crutches)
4. Reformation (do it again if it doesn't work)
5.psoas consists of 60% tendon 40% muscle at LT, hypothetically more thorough release at LT
6. Instrumentation heading toward neurovascular bundle which, if unfamiliar by OS, may lead to damage
7. more complete release theoretically may lead to more post-op weakness 8. conversely less of a release is needed at central compartment because that is where the tendon (GROIN PAIN) is being impinged upon.
9. more complete release. at LT, the psoas is 60%tendon compared with 40% tendon in central compartment-saving muscle
10. surgically unaltered area minimal scar tissue which may decrease the risk of subsequent hip instability vs central - scar tissue after THA ( the lesser trochanter is more of a "virgin" and less complications when doing release because no THR at this location)
does not violate hip joint , which may decrease the risk of subsequent hip infection due to direct innoculation.

Disadvantages
1.too far from capsule where groin pain is- may not relieve groin pain
2. release total psoas tendon (not partial) - weakness in leg, greater loss of flexion (can you do partial LT Release?)
3. close to femoral neurovascular structures
4. need complete release (symptoms remain) double, triple band may be present .
5. approach is less familiar to hip arthroscopist as most lengthen the psoas in non-THA patients in central compartment
6. less visibility
7. approach is less familiar to hip arthroscopist as most lengthen the psoas in non-THA patients in central compartment release of a larger portion of tendon will allow more lengthening of the tendon and result in lower chance of continued tendinitis
8. instrumentation heading toward neurovascular bundle which, if unfamiliar, may lead to damage
9. more complete release, theoretically may lead to more post-op weakness


Central Compartment
Advantages
1. more visibility
2. less of a release is needed at central compartment because that is where the tendon (GROIN PAIN) is being impinged upon.
3. approach is more familiar to hip arthroscopist as most lengthen the psoas in non-THA patients in central compartment
4. 40% tendon -60% muscle at central - less loss of hip flexion

Disadvantages
1. In hip capsule - greater risk of infection and dislocation (hip instability)
2. Extended rehab - 6 weeks crutches

Comments, additions, corrections, welcome.
Did any of you experience the above in your release. Is it accurate?

 

[SaraK]

I'd ask RE 6 weeks on crutches. I was told that's necessary for many arthroscopic because they have to dislocate or come close to dislocating the hip. By contrast, some tension used for central compartment release but not nearly as much. I used a cane for a day or two and had no mobility restrictions. I did PT but was told it was my option. I went out to dinner and dancing for NYE on the day of my surgery - with my surgeon's full blessing. He was also ok with me getting on bike, lifting weights or doing anything else immediately so long as it didn't take my pain level above a 4.

My surgeon left STL and went back to Montana or Wyoming where he was from.

 

[Mojo333]

In my area, this surgeon is much talked about...don't know about tendon release but would think he does .
https://hipfootankle.com/

I don't have any first hand experience as you know. Glad you are going to get this seen about...time to get back to pain-free and healthy and happy!

 

[Jws.]

Josephine, SaraK

If I remember, yours was central compartment release. So he went into the capsule, that's why 6 weeks on crutches. For the central capsule release it is a much longer rehab as they go through the capsule and need to heal, etc., for stability.

The lesser trochanter is a much easier procedure with far less risk of infection or dislocation because not going near hip capsule. However not sure as to the relative weakness or loss of hip flexion in LT release. They say maybe 10% more deficits but heck, you don't have the risk of instability, infection (not as great) and the rehab is much less onerous..

My main concern is if it doesn't work at LT because the release isn't close enough to the central compartment to give enough loosening to where the actual groin pain is originating and where generally the psoas directly impinges on the capsule (central compartment) then can you get a "do-over" in the central compartment without risking too much hip stability (because you already released the psoas at the LT and now you are again releasing at the central compartment) not much holding the hip in..??(except for the rectus muscle?)???

Hope that wasn't too convoluted. thoughts?

My concern and thoughts are;
If I was sure I would get enough loosening back up to the central compartment (where the groin pain originates) by fully releasing the psoas at the lesser trochanter and not much more loss in hip flexion or leg weakness than a central compartment release, I would do it in a heartbeat at LT! Thoughts? help? Info? thanks

 

[Mojo333]

You've definitely done your homework and have thought of all contingencies.
I'm guessing Josephine is off forum for the night...but I'm sure she will add her thoughts tomorrow.
Sending all the best mojo your way for the best solution!