Hip Arthroscopy 3 yrs. post op and exercise has not made much difference

[Jamie]

When you see this new therapist, ask if they do Pressure Point Therapy. After my hip replacement, I developed small knots on my quad muscles and this therapy worked very well to eventually get rid of them. It’s a simple technique where the therapist locates the knot(s), then puts finger pressure on them for a period of time. This causes a release of the knot. At first, they do come back, but with continued pressure treatments, the knots are eventually resolved.

I image a similar result can be obtained with the right type of massage therapy. Good luck and let us know how it goes.

 

[benne68]

how long do you think it took to resolve the knot in your glute?

I honesty don't remember -- I lived with the problem for so long that any relief was welcome.
As I mentioned above -- the problem does return if I don't keep up with both the massage and yoga. When it flares up, it is painful to sit. I either lie on the floor or stand!

And has the knot truly “disappeared” for you?

No, but it does recede enough that I can sit comfortably for extended periods. I suspect the root of the problem will never completely go away unless I opt for back surgery -- which I am not inclined to pursue at this stage.

Good luck with your physical therapy!

 

[frogger]

As I mentioned above -- the problem does return if I don't keep up with both the massage and yoga. When it flares up, it is painful to sit. I either lie on the floor or stand!

I see. For me the problem can make it painful to sit and this was worse/stronger during the disc herniation 6 months ago. Which does suggest they're strongly connected.

No, but it does recede enough that I can sit comfortably for extended periods. I suspect the root of the problem will never completely go away unless I opt for back surgery -- which I am not inclined to pursue at this stage.

By "back surgery", were you imagining microdiscectomy?

I saw a spinal surgeon but they felt the herniation relatively small. For this reason, she has requested I have the electrogram exam, in which they test the nerve and determine whether it's under pressure/pinched at the moment.

I now believe the problem is spread across these 3 areas: the disc, the piriformis/trapped nerve and the labrum damage.

And for this reason, I don't even know if microdiscectomy would help me. If the nerve is trapped in the glute then surgery to relieve pressure on the nerve at the disc level wouldn't help. Right?

I don't really see how I can recover all of this. It feels like there's so much damage it's hard to believe I can recover with just physiotherapy, stretches or massage. I thought by having the hip surgery I would be on a clear path to returning to proper exercise and now I just feel I've lost another 3~ years of my life.

 

[frogger]

@benne68 if you don't mind, I have some more questions to ask you about your piriformis pain.

My goal is to understand how similar our problems are to determine just how likely a conservative treatment that has helped you might help me:

Where does the pain normally appear?

• The glute?
• The hip joint?
• The front of the thigh?
• Or all of these?

Do you find that when you bend forward on one leg, that your hamstring/joint will "pop" as you tilt/lean forward? This happens to me on both sides but especially on the right side and it releases the pain/discomfort when it happens.

Which stretches help you the most? I've seen the following recommended for piriformis in the past:

• Half pigeon pose in yoga.
• Figure 4 stretch.
• Seated ankle over knee forward stretch.
• Frog pose in yoga.

Which exercises help you the most? I've seen the following recommended for piriformis in the past:

• Glute bridges
• Lateral band walk
• Lateral leg raise

 

[benne68]

Hi @frogger,

Happy to answer your questions, but I do want to remind you that our herniations are in different places. Although L5-S1 is close to L4-L5, when the discs bulge they press on different nerves so our symptoms -- as well as the solutions -- may be different.

1. My pain occurs predominantly in the piriformis and the IT band, but occasionally all of the above.
2. No popping.
3. Figure 4 stretch is my go-to. Since my hip replacement, I no longer do pigeon or frog.
4. None of these. It's the work to strengthen the lateral core muscles (not the abs) that has been key to my improvement -- since that provide better support for my spine.

I don't really see how I can recover all of this. It feels like there's so much damage it's hard to believe I can recover with just physiotherapy, stretches or massage.

I felt that way, too, initially. Perhaps you are expecting too much too soon. Keep in mind that your hip surgery in 2021 would not have done anything to improve your bulging disc. They are separate problems.

Since your herniation was only six months ago, perhaps you just need to give the damage time to heal.
Unfortunately, recovering from back problems require a lot of patience.

 

[Jaycey]

I don't really see how I can recover all of this. It feels like there's so much damage it's hard to believe I can recover with just physiotherapy, stretches or massage.

Having been through this spinal journey I can tell you that physio to build core stability does indeed help. I had years of it before finally having spinal decompression.

Post my LTHR I had several instances of major piriformis pain. Hamstring stretches and trigger point massage by a specialist spinal PT helped ease this. Unfortunately spinal issues can be a major drain on patience!

 

[frogger]

1. My pain occurs predominantly in the piriformis and the IT band, but occasionally all of the above.
2. No popping.
3. Figure 4 stretch is my go-to. Since my hip replacement, I no longer do pigeon or frog.
4. None of these. It's the work to strengthen the lateral core muscles (not the abs) that has been key to my improvement -- since that provide better support for my spine.

It’s interesting you describe it as “piriformis pain”. For me I feel it in the glute but I can’t really say for sure that it’s “the piriformis” in particular that’s hurting.

I have no pain in the IT band. But I have discomfort across the front of the thigh. Often clicking or popping can occur across the front of the thigh which relieves the pain.

Thanks for answering all these points. It’s interesting to see the contrast. I think our conditions are similar but likely still different enough that I’ll need to find my own custom routine. Because if just “figure 4” stretching and a stronger core was enough for me then I’d likely have improved by now. As I’ve had PT at various points in the last 10 years and tried those options.

Perhaps you are expecting too much too soon. Keep in mind that your hip surgery in 2021 would not have done anything to improve your bulging disc. They are separate problems.

Yep. For sure. I wasn’t conflating the two. Although I believe that one can cause the other, I know that fixing one doesn’t fix the other.

At this point, I recognise that there are some more scans to do and consults to have. But I will explore a new conservative treatment with the new PT and focus on this “glute issue” with trigger point, exercise and stretching.

If that doesn’t work, I think a surgery for my L5-S1 disc might be in the cards to relieve pressure further.

 

[Caspa]

Hi Frogger. I just had my hip replaced 8 weeks ago. I have a really messed up back too. Stenosis, scoliosis, multiple herniations in all three sections with the worst being at L5-S1, arthritis etc. I had laminectomy for a major blow out at L4-L5 over 25 years ago. For the past few years I've had debilitating back, hip and knee pain. I had a partial knee replacement a year and half ago that didn't work so well but I blamed it on my bad hip. I was told by numerous doctors that my back pain was not related to my hip but I decided to wait until after my hip replacement to start epidural injections in my spine. (I tried PT for six months with no relief). Well, the hip surgery relieved 80% of my back pain. It did nothing for my knee pain though. My point is that this is all connected so it's really hard to tease out the source of pain when you have multiple issues. In my opinion, your hip should be better by now. Get a second opinion. But...don't rule out it could be that herniated disc. Microdiscectomy is an amazing operation. My brother has had three, my daughter one...each experienced immediate relief. I really hope you can find out soon what is going on. You're too young to be feeling so rough!

 

[frogger]

@Caspa Hey Caspa, thanks for the thoughts. Sorry to hear about your journey and yes I agree I'm too young for this... although I'm ok to have injuries as long as they get fixed. What I hate is how long it seems to take before it becomes clear that whatever I've tried/done (surgery, PT, etc) was not the solution and there's still more to be done.

For my hip, it's true the joint itself should be better but pain in the hip and inflammation can be triggered by the pressure on the nerve at the L5-S1 disc or via sciatic nerve entrapment in the glute itself. So maybe the surgery was successful but there's more I needed to solve.

Ultimately I think the answer is it's still just a combination of "all of the above". I think my cartilage is in a bad state and thus the joint itself will always create some inflammation with relative easy (unless I get a total hip replacement).

And I think the disc is now pressing a bit more which will always create some inflammation easily as well (unless I do a microdiscectomy).

My new PT wants us to try:

• Strengthening my core again to relieve pressure on that L5-S1 problem.
• Mobilizing/rewiring the hip and glute movements to free the nerve in the glute muscles.
• Strengthening my hips, glutes and thighs to relieve pressure on the hip joint / cartilage.

Honestly, I think this is a good plan. And I think the part that hasn't been explored to its full exten before is the second part – untrapping the nerve in the glute.

If after this, there are still problems. I might start with the microdiscectomy surgery. And if after that, there's still problems, I will look into total hip replacement. It seems extreme but I want this solved for the next 10 - 15 years. And after that, I will take my chances on medicine improving to enable another hip replacement if needed.

I'm open to any thoughts on my plan above if anyone has any...

 

[mendogal]

I don't think there's harm in another try at conservative treatment with PT.

Did you get the scan or test you recently mentioned? Has it been suggested you try a temporary nerve block at the level of your disc problems to see if it resolves the pain?

 

[frogger]

Did you get the scan or test you recently mentioned?

No yet. First available appointment isn't until 2nd of May for the test.

Has it been suggested you try a temporary nerve block at the level of your disc problems to see if it resolves the pain?

I've had 2 epidural injections in the last 6 months and they helped reduce the day-to-day pain for a few months.

 

[frogger]

Hi all, I wanted to post another update. A few things since my last post here:

1. I returned to PT and the gym. My PT has been focused on hip mobilisation and in particular I've been finding that the Copenhagen plank helps reduce my pain and symptoms.
2. As this targets the adductors, I have tried using a weight machine to strengthen my adductors. I've discovered that if I "push myself too far" with this though, I get a lot of hip pain.
3. I had the EMG scan/test for see if my muscles and nerves have shown degradation from the back herniation. All the tests were normal/successful. And in general, while my back is often stiff and I'm careful with it, I think it has healed substantially. I don't think that my hip pain is caused by the discs currently, I think it is indeed the hip itself.
4. I did some vacation and work travel in the last 2 months and my routine was not very consistent so I have not lost weight. However I think I've replaced fat with muscle at least.
5. At the gym, I'm just strengthening with squats, lunges, cycling and upper body work. And doing hip mobilisation on top of that. I'm not trying to return to running at this point.

The other day, I pushed myself too far with the adductor weight machine and 2 days later, I had a lot of hip pain. I continually wanted to pop the tendons around my joint. I couldn't shake the feeling. I took 200mg of ibuprofen and later on, I made a movement where I shifted my hips/weight between two legs while standing and felt a very distinct "thunk" as if something was released deep in the joint. I felt relief after this although there is still residual pain, as if now the joint can "calm down" now that it was resolved.

Honestly, I feel like what I felt was a shift in the position of the ball in the joint and potentially the labrum flipping around. This was hip impingement I assume?

One question I have now is... does this suggest my surgery needs a revision? Should adductor exercises really be able to trigger this problem so easily? I think I pushed myself up to 28kg on the machine, 14kg for each hip.

I've just re-read some of my posts this year and I feel, based on the above, the following thoughts:

• I don't think my current hip pain is caused by the discs.
• I don't think my nerves have suffered long term damage from the herniation.
• I don't think I need the microdiscetomy at this point.
• I wonder if a hip replacement is necessary to consider at this stage.

As usual, any thoughts are appreciated.

 

[frogger]

Well, I'm back again here to give more updates/thoughts.

In the last 3 months I worked really hard on physio therapy and returning to fitness. Perhaps more than any previous effort I've tried. I've avoided running and focused on cycling with weight training and mobility.

Let's start with the positives:

• I've lost a few kilos of weight.
• I've put on a good amount of muscle and lost fat. My lower body / legs are definitely stronger.
• My back is definitely stronger. I don't really feel anymore back problems overall.
• I feel better mentally overall... however...

...the negatives:

• I've had to use ibuprofen regularly to keep the inflammation down. Twice a month for 3 days at a time.
• My hip can still very, very easily get irritated. From cycling or efforts to strengthen the hip (e.g. squats, leg press).
• I feel I am in pain every week. This feels like how I was before the original surgery.

Honestly, I think I'm on a collision course for a total hip replacement within the next couple of years.

This arthroscopy and recovery have not gone smoothly at all. I spoke to my surgeon last week and here are some of his thoughts:

• Firstly he agreed I'd had it rough.
• He would like to see me lose more weight but considering cycling can provoke the problem, I really don't see it helping overall.
• He has proposed 3 options for injections.
• He'd rather I didn't have a total hip replacement until I'm at least 40 years old (which is now roughly 2 years away anyway...)

In terms of injections, he explained there are 3 options:

• Cortisone
• Hyaluronic acid
• Platelet rich plasma (PRP)

I've read a few studies about all 3. My understanding is that we now know that cortisone, while effective short term, leads to quicker degradation of the cartilage long term (I had this injection 4 years ago actually.)

Hyaluronic acid when compared to placebos actually might not be very effective it seems.

Finally PRP shows benefits in comparison with cortisone for long term and in comparison to hyaluronic acid and overall seems promising. However, I found a more recent study showing it might also be in our heads – when compared to a placebo it was a similar situation of not being very effective. I also searched heavily for anecdotal evidence (forums, etc) of PRP benefits and it seemed like most people were negative on them.

Which leads me to think THR is going to be necessary.

I'm nearly 38 years old and it depresses me greatly to think I'm going to need THR at my age. I feel like my life with this problem just continues to deteriorate and it's something of a spiral. I fear I will never be free of this condition until I have THR and even then, I imagine 15 - 20 years later I'll need it replace again. At which point I'll be 55 - 60 years old. I may even need 3 hip replacements to cover my life if I live beyond 80.

Any thoughts would be appreciated. Especially around the benefits or negatives of going the THR path within the next year. Because I think I'm willing to give PRP a try for 6-12 months and if it doesn't help, it's THR time

 

[djklaugh]

@frogger I am sorry to see you are still having such problems with your hip. How long has it been since x-rays were taken of the hip? Alas when a hip is deteriorating nothing will really fix it .... it will continue to deteriorate and can get to the point that it collapses which is an emergency situation and extremely painful. The injections you mentioned are more about managing pain and not really about repairing damage already done to the hip joint.

Yes you are young but here at BoneSmart we are seeing more and more people needing hip replacements at your age or younger. We have even seen several teenagers getting new hips! About a year ago there were 2 police officers about your age who got new hips and returned to active duty. In my opinion it would be best to keep the focus on the condition of your hip joint and not so much on your age. If it needs replacing then it needs replacing! Be thankful that medical science has given you this option.

These days the hip implants are expected to last for 30+ years ... so you might need a revision late in your life but you would have 30+ years of pain free hip and enjoying your life. Given the pain you have now and the lessening mobility, do you honestly think you can get through 2 more years? Could you perhaps seek a 2nd opinion from another hip surgeon who is not associated in any way with the one you have been seeing? Perhaps one who specializes in treating younger patients?

 

[frogger]

Hi @djklaugh thank you for your reply. I really appreciate it.

How long has it been since x-rays were taken of the hip?

Last x-ray was about 1 year ago as a checkup. The corrections to the bone structure were still good for preventing FAI.

The injections you mentioned are more about managing pain and not really about repairing damage already done to the hip joint.

Regarding the injections, I agree with you - I know it won't reverse the damage. My understanding is that none of the injections have regenerative capabilities. But they can attempt to preserve the cartilage in a more "neutral" state where it won't decay further and thus prevent bone on bone contact. However, I imagine the cartilage will simply break down either way in the next 10 years.

In my opinion it would be best to keep the focus on the condition of your hip joint and not so much on your age.

I agree that's a good way to think about it. I'm just scared about the future now and the impact long term of doing it so "young".

These days the hip implants are expected to last for 30+ years

That is reassuring but I believe it depends on how active the person is. Even if they're lasting 30 years, that would likely be for older people. As a younger person my understanding is it would last less.

Given the pain you have now and the lessening mobility, do you honestly think you can get through 2 more years?

My mobility is actually ok. My flexibility is ok. I've always had flexible hips strangely enough.

The only problem is the pain, which comes around if I exercise. If I medicate with ibuprofen I can suppress it but that's not good long term and it's never 100% out of my mind.

Could you perhaps seek a 2nd opinion from another hip surgeon who is not associated in any way with the one you have been seeing? Perhaps one who specializes in treating younger patients?

It's true I haven't sought a second opinion. I can look into this.

Technically my current surgeon in France is the third surgeon though. The first two I spoke with were back in Australia. It saddens me greatly that this problem was misdiagnosed by Australian doctors for nearly 2 years, then I moved to France and lost time due to COVID before I could be operated. On top of that, my pain began slowly a few years before I sought advice in Australia. Looking back on it... the timeline is haunting:

• 3 years of slow onset of pain
• 2 years misdiagnosis
• 1.5 years of waiting due to COVID
• 3 years of post-surgery attempt at recovery

Maybe if I'd had the arthroscopy as soon as symptoms appeared, this would all be very different. I'm approaching nearly 10 years now of this.

 

[Jamie]

It really will help you to get at least one more opinion….maybe two or three. We do have a fair number of our membership who are young and get hips replaced. When it needs to be replaced, it needs it, if for no other reason than to give you a better quality of life while you can enjoy it. No one knows how long your hip will last, although the studies are now pointing to more longevity from this surgery than in the past. Time will tell.

The decision of when to have a bad hip replaced should be yours and not a surgeon who thinks you need to wait until some magical date when you are “old enough.” You are the one living your life and should be able to live it the way you choose.

Seek those other opinions and you may have a different outlook on what will be best for you. With a hip replacement, you do obtain the chance to live your life not being constantly dealing with hip issues.

 

[myglasshalffull]

I have a young friend (40's) who has undergone two hip replacements in the last year due to deterioration & bone on bone & he's doing fantastic. His brother had one hip replacement a little over a year ago, a little older but not much & he's back skiing.
My son was 21 when he was in an accident & smashed both his knee caps necessitating surgery. He's now 48 & an ER nurse with very busy life & two young kids.
So just because you are young does not mean you will need more replacements in years to come. As Jamie mentioned these replacements have come a long way & last for many years.
All my best.

 

[Hip4life]

@frogger Here's my take on this: you are already saying how the hip pain is affecting your life and lamenting the time lost to it. That is what you need to judge a hip replacement against. I probably spent 3-4 years dealing with the pain and popping ibuprofen, etc. to help. Then another 18months of ever increasing pain, with various diagnoses, until I finally got the correct one. Bone on bone osteoarthritis. I was older than you, of course, and your course is a bit different, but I would have jumped at the chance to have lived that time without that awful, ever present, ever advancing pain. Me being me, the longevity of the implant wouldn't have even entered into the equation. Maybe some would consider that foolhardy but with my life experiences, life is too short to live in pain if there is a solution.

You've already been through a surgery that takes some time to recover from, the injections have their drawbacks as well as being pricey and not usually covered by insurance (at least here in The States.) I think, like those above, a good second opinion could give you a better handle on this and help with a decision. Bottom line: it's your decision. It's not an emergent situation so you don't have to feel pressured into a decision right this minute. Like one of my docs once said: "even not making a decision is a decision." I think if you give yourself permission to decide without having to take your age into account, you'll know what to do and when, in time. Wishing all the best going forward. Keep us in the loop.

 

[frogger]

Hi all, thank you for your thoughts I'll respond to each of you individually.

@Jamie

• You're right. I've organised to see another surgeon just to get a fresh perspective. I've booked that for September. Most people are on vacation in August in Europe.
• The idea that a hip replacement really would fix everything would be great. I still have a fear that there will be more problems though. I guess since nothing has been easy so far in this journey, and I've gotten so many promises along the way, it's hard to believe it anymore.

@myglasshalffull

• If a hip replacement restores my right hip completely, I'd like to try returning to running (nothing crazy, just as part of my exercise). I imagine if I do that, it'll deteriorate the prothesis faster but I also hope it would last a long time.

@Hip4life

• You're right. I think part of me is just struggling to accept this reality that the arthroscopy just didn't really work. But if a THR is needed then I must accept that.
• Regarding cost of injections, I believe it won't be too expensive. I live in France and the health cover here is quite good. I am willing to try injections for 6 to 12 months and if I don't see substantial improvement, then take the path of THR.

Some final thoughts:

• I recently started taking glucosamine and collagen to see if there were supplements that could help my hip. I've been a bit surprised to find it's feeling better. I wonder if others on the forum have had success with these supplements?

Thank you again all for your kind words.

 

[frogger]

Hi everyone. I wanted to provide some new updates. I'm amazed to see that it's been 2 years since I last posted on the forum.

Unfortunately my situation has been up and down in the past 2 years but still trending downwards. While my back herniation feels like it has mostly healed, my hip continues to give me problems and have flare ups. Even though I've strengthened myself with deadlifts and glute exercises, the joint can still easily become inflamed and taking ibuprofen became my ongoing solution mixed with PRP and Hyaluronic acid injections.

However, I recently had an injection that gave me great relief for 3 weeks and then quickly faded away. This prompted me to speak to my surgeon again. He ordered another x-ray to check on the space in the joint and whether there was still cartilage available.

In theory, there is enough cartilage in the joint. However, I still have regularly pain and inflammation. My surgeon explained that at this point, it seems that we can only conclude that while I'm "mechanically fixed", he now thinks my cartilage was simply too traumatised over the years with inflammation and it is "biologically broken" – in other words, exercise or even general use of the hip quickly triggers inflammation which in turn triggers muscle guarding and pain.

Now that I've turned 40 years old and he feels I've tried enough to rehabilitate without another surgery he is willing to move forward with a total hip replacement. He had been so cautious to do this because he hates when a young person who seemingly still has cartilage in the joint goes down this path but then has complications and ends up regretting the decision.

I discovered two more things which I believe further indicate I really need to do this.

#1 - My average steps per day are on average declining:

I didn't realise this until I pulled all the monthly data from my phone and graphed it.

I think this graph highlights that part of my pain management in the last few years has been a subconscious shift towards "shrinking my physical world to reduce my pain". I didn't even realise how much it had declined.

#2 - My weight has climbed significantly:

While I've gained muscle at the gym, I can't help but notice that my weight has ballooned again since the back herniation and presumably due to my reduce steps per day and continuous battle to exercise while managing my pain. When I originally had the surgery I was at 73 kilograms. I'm now at approximately 84 kilograms. While I've attempted to lose that weight and did reduce it to around 78 kilograms, it has seemingly crept back up once more.

Why I'm posting here again:

I've researched the surgery quite a bit and the possible complications (infection, dislocation, uneven leg length). Obviously none of it sounds good but I just can't imagine trying to live my life further like this. I have bad days at least once a month and I'm always cautious with my hip. Even when there aren't flare ups, it feels like there's always some background "noise" which I guess is this continuous inflammation. I went on vacation recently and just travelling in the plane caused persisting pain and walking for long days caused persisting pain.

None of these activities "cause pain in the moment", it is not like bone on bone pain. Instead it seems the usage of the hip capsule triggers an inflammation cascade which results in persisting pain for days which can extend as the muscles/tendons around the area became further agitated (glutes, psoas, lower back).

My questions for this community:

• Is this abnormal? The fact that I have cartilage but I've entered into this inflammation loop with the quality of the cartilage?
• Are there other patients who had a total hip replacement because of this situation I'm describing rather than bone-on-bone symptoms?
• Do you think there's any remaining solutions that I may not have tried? Is there any chance that the joint is regularly inflamed by other factors like a shortened psoas muscle or IT band? Anything where less invasive (and non reversible) surgeries could help (e.g. psoas release or PRP injection into the hamstring, etc).

I'm not afraid of the surgery itself but I am afraid of taking a course of action that is irreversible and turns out to not solve my pain and fix my life.

Thank you again to this community for listening.

PS: I know in my last messages 2 years ago I said I would seek a second opinion. I did, I saw another hip surgeon in Paris but when he saw the scans and the amount of cartilage left he didn't think it needed a hip replacement. An extra piece of irony: this second surgeon's secretary's daughter needed a hip surgery a few years earlier and I suppose because the surgeon didn't feel comfortable operating on someone personally close to him, he instead sent her to the best surgeon he could think of – which was actually my original surgeon.