THR Can't do a straight leg lift, groin pain

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This thread caught my eye because at my first post-op PT they had me try the leg lift (lying down) and I could not do it. I had an anterior incision and I had groin pain because they retracted those muscles during surgery. At my second PT, they told me we were not going to do that exercise because my surgeon told them he didn't want any of his patients to do it. My groin pain is much improved a week later but the in-home PT guy also said he had received word not to do it. Just for what it is worth.
 
Last week I emailed my surgeon the article Josephine had posted (Iliopsoas Impingement after THR) and told him I felt this might be the reason for my on-going problems (I have ALL the symptoms), and that I want to have the appropriate scans to confirm yes or no. He wrote back that my suspicion may be correct. He said, "It's rare, but it does happen." I'm seeing him on Tuesday.

I have searched the internet for more articles on this topic. Apparently IPI happens with about 4.3% of THR patients. In one study I found, it said that "Conservative measures" failed in all such cases. The most invasive procedure, revision of the acetabular component, resulted in a lot of complications. The "middle of the road" solution of iliopsoas tenotomy seemed to give the best long-term results with the least complications. However, it was a small sampling (only 29 patients). I have quoted the abstract below.

Just the thought of having more surgery makes me feel sick. I have to really think about whether I should just live with "the devil I know" or take the risk of something else going wrong if I go under the knife again.

Arrrgggg . . .


J Bone Joint Surg Br. 2007 Aug;89(8):1031-5.​
Iliopsoas impingement after total hip replacement: the results of non-operative management, tenotomy or acetabular revision.​
Source​
Department of Orthopedics, Balgrist University Hospital, 8008, Zurich, Switzerland.​
Abstract​
We have reviewed a group of patients with iliopsoas impingement after total hip replacement with radiological evidence of a well-fixed malpositioned or oversized acetabular component. A consecutive series of 29 patients (30 hips) was assessed. All had undergone a trial of conservative management with no improvement in their symptoms. Eight patients (eight hips) preferred continued conservative management (group 1), and 22 hips had either an iliopsoas tenotomy (group 2) or revision of the acetabular component and debridement of the tendon (group 3), based on clinical and radiological findings. Patients were followed clinically for at least two years, and 19 of the 22 patients (86.4%) who had surgery were contacted by phone at a mean of 7.8 years (5 to 9) post-operatively. Conservative management failed in all eight hips. At the final follow-up, operative treatment resulted in relief of pain in 18 of 22 hips (81.8%), with one hip in group 2 and three in group 3 with continuing symptoms. The Harris Hip Score was significantly better in the combined groups 2 and 3 than in group 1. There was a significant rate of complications in group 3. This group initially had better functional scores, but at final follow-up these were no different from those in group 2. Tenotomy of the iliopsoas and revision of the acetabular component are both successful surgical options. Iliopsoas tenotomy provided the same functional results as revision of the acetabular component and avoided the risks of the latter procedure.​
 
OldGal StaceyA
Thanks for posting the info above OldGal !- I'm sorry that you and StaceyA are having problems. I have severe bilateral groin pain that started week 5 after my BTHR. An ultrasound showed tendonitis and some bone spurs. The OS injected the hip joints with cortisone last Tues, but I've had only a little relief that was temporary. Now I'm worse than I was before the shots.
I'm also wondering if there could be more wrong than the tendonitis, like impingemet - please, please keep me posted on what tests will be done for you, and what the results are. Do you know which tests help to diagnose this? I'm desperate for help, as this has totally changed my life and now I'm in pain nearly all of the time. I was a healthy, active person before this happened, and now I'm almost dysfunctional.:sad: It's just terrible.
Thanks for any information that you can provide so that maybe I can get some answers. Take care and please let me know how you are both doing. Good luck!:friends:
 
ByGosh
One of the articles I read said: "The diagnosis may be confirmed by one or more imaging studies, including a cross-table lateral radiograph (I assume this is an X-ray?), computed tomography (CT), magnetic resonance imaging (MRI), and ultrasonography, in combination with a confirmatory diagnostic injection." I'm seeing my OS tomorrow and will find out what he recommends.
 
OldGal Thank you for that info! I appreciate it very much.
I had an ultrasound and just had a CT scan. I'm waiting for the results of the CT scan.There was no mention of impingement on the USound, but I don't think that's the best imaging for this. I had steroid injections in both of my hips last week, which have not helped.
I'm interested to know how you make out and what your OS says. Please keep me posted.
Good luck tomorrow! I'm thinking of you. :friends:
 
ByGosh, when my OS diagnosed Trochanter Bursitis last September for my un operated hip, he offered me a cortisone injection but then told me they are not always successful.. I researched and researched and found that rest was the best option for me, so stopped my Nordic Walking for a few months and it is so much better... I really hope you can get some relief soon :)
 
Update: I saw my OS on Tuesday, and on Thursday he had me in the operating room for a steriod injection into the hip joint (under X-ray and anesthesia). He says, in his experience, about 50% of the time the injection permanently resolves the problem of the groin pain, and 50% of the time it doesn't. If it doesn't, then one has to make a decision as to whether to have a tenotomy, i.e., release the tendon that is impinged.

He says that for a tenotomy they enter through the same scar where the THR was done, and that recovery time is about the same as from the original THR! This really surprised me, because one of the articles I had found online talked about doing the tenotomy arthroscopically, but my OS says that is not a procedure he is familiar with. I looked at the article again and saw that it came out of Germany, so maybe this is one of those surgical procedures where the U.S. has not caught up with other countries. Or maybe it's just my HMO that isn't up to speed.

Immediately after the procedure, the nurse who was wheeling me to my car asked if I was feeling any relief from the procedure. I said no. I could tell she was disappointed to hear that, but then she said sometimes it takes a while to see the results; my OS says it can take a few weeks. So far, I have noticed no change -- I still have groin pain when entering and exiting the car, lifting my knee to put on shoes, turning over in bed, etc. BUT . . . it is not severe. If this doesn't work, and if I cannot have an arthroscopic tenotomy, then I will probably just give up and live with what I have.
 
so maybe this is one of those surgical procedures where the U.S. has not caught up with other countries
Or more likely the procedure never took on because it was largely unsuccessful. Arthroscopy into this area is phenomenally difficult for technical reasons and it's much safer for the surgeon to do it under direct vision as there is a major artery and nerve running quite close to the tendon. He absolutely must identify those before he cuts anything and I think you would want him to - don't you?
 
Or more likely the procedure never took on because it was largely unsuccessful. Arthroscopy into this area is phenomenally difficult for technical reasons and it's much safer for the surgeon to do it under direct vision as there is a major artery and nerve running quite close to the tendon. He absolutely must identify those before he cuts anything and I think you would want him to - don't you?

Hi, Josephine. What you said is exactly the concern he expressed . . . and yes, I would definitely want him to be able to see what he's doing!

But again, unless the pain gets worse, I will probably opt to live with what I have. After having one TKR and two THR's in close succession, and each one a long and difficult recovery, I just can't face another surgery unless it's absolutely necessary.
 
Hi Stacey,
I read your thread. I have the same issue. I had a left THR anterior approach 15 months ago and noticed on day one in the hospital that I had groin pain and that I could not lift my leg. You are 8 months post op, correct. It is still impossible for me to do a straight leg lift while in a seated position on the floor. I am supposed to do the injection into my tendon, but my insurance will not pay for it into the hip. Insurance would pay for it in the knee, however, it is only considered as diagnostic. Can you explain how your doctor determined that it is not an impingement?
I have to help my leg with my arms to get into the car or into bed.
Did you have the anterior approach?
I know the pain you are experiencing and it's horrendous. I am sorry that you are still having pain. I can tell you that it did get a little better in the first year, but I know now it will be a chronic problem. I understand there is a tendon release surgery but if yours is not an impingement, what are they saying?
I just wanted you to know that others are reading your post and in the same boat. :)
 
Oh dear, I'm having the same issue, having a CT scan tomorrow and was hoping for a steroid injection as a first step. Who is your insurance carrier? I hope my insurance company doesn't reject this potentially important diagnostic/treatment tool! Have you attempted to talk with the powers that be?
 
I have found all these entries very interesting.
I had a THR ceramic march 2010 four years ago aged 48 and have been in pain ever since in the groin, unable to get in and out of bed, the car, ride a bike, climb stairs without lots of pain or lifting my operated leg with my hands to experience less pain. I am unable to raise my leg when lying down. I have seen my surgeon a couple of times who says there is nothing from his side wrong. They did crack my leg when they did the operation so I was on crutches for 5 weeks before I could weight bare in the first place. One leg is longer than the other which I have grown used to and have back pain on and off, but am unable to stand with legs together. Have to stand at ease! I have had MRI's, CT scan, injection into the the muscles to ease pain but that made things worse. Nothing was noticed on the scans to be wrong so no further forward. I take codrydamol and dicolfenc when it is really painful. I think reading the other posts that the next step is seeing a neouoligist. I haven't been keen on another operation, one surgeon suggested we do key hole surgery and investigate. I am frightened of getting an infection in the joint. I do worry what I will be like in 10 years time and there is no way I could have the other hip done. Thankfully that one is fine at the moment.
 
not so. I had my iliopsoas released arthroscopic and the proceedure was great. He released it from the lesser trochanter and did not go into the hip joint. This was the best decision I have ever made. I have had my left hip replaced now (different surgeon) and I'll be damned if my groin is killing me. I did have to have that one revised to put a different ball (to lower my left side a bit) about 8 weeks ago so I am not getting hasty, but I will not hesitate to do it again if that pain persists. By the way, that is the exact pain I have and I have had it before in my right hip before I had the tendon released.
 
StaceyA,

How are you doing these days? I hope better. I know that pain well.

Hi, I have had the same problem with pain when trying to lift my leg (straight leg), or marching. Also, I had that excruciating pain initially when I did a straight leg lift earlier (some time after my THR - maybe 6-8 weeks post op, I can't remember now). It is now 2 years post op. I had to go back to PT because my leg and hip were so weak. I had a full PT treatment again and I feel much better. My groin does not hurt nearly as much now, but it still does hurt some and I have some restricted movement still. It seems on cold days my muscles get really tight. I still go for massage therapy every 2 weeks and I think that really helps. I am now finally back to the gym thanks to my fabulous PT.

I had injections, and a CT and an MRI. My surgeon said I do not have psoas impingement (I was convinced I did), but my surgeon did say if I want, he can conduct surgery and he thinks it is either 1) psoas needs to be cleaned up 2) capsule needs to be cleaned up or 3) implant needs to be repositioned, because in 30% of cases now, with the bigger balls they are now using, they have learned they need to be positioned differently somehow. That 3rd one sounds like psoas impingement to me, though! I certainly do not want to undergo surgery again, so I am in a wait and see pattern right now.

Good luck, and I hope things have gotten better for you.
 
@Dancer22 Hi I haven't been on this site for some time but just happened to come across your post whilst browsing.I am in a similar situation to yourself with persistent groin pain which was very intense when I tried to bring the knee up towards the chest.I had an ultrasound in January which showed psoas tendinitis but the OS changed the diagnosis to tendinosis I his last letter.I had a course of physiotherapy for three months which has helped to strengthen the hip and to help the ROM.I am at last seeing the benefit of the exercises but it has taken over three months as the hip was very weak and I had to take it very slowly.I still get discomfort in the groin but it has definitely improved.I have never tried massage and I am very interested in the sort of massage you have and how you chose the practitioner.
 
Hi Kim22, I am 2 years post op for a left total hip replacement (THR), anterior approach. Even before my THR I remember I had pain in my psoas, even a year or 2 before.

Anyway, I kept going back to my doctor post op with this continued pain - he did a catscan and an MRI, and did not find anything other than an atrophied piriformis. I was afraid of psoas impingement, and thought for sure I had that because there was a fair amount of pain. I went to PT after my surgery like I was supposed to do, then BACK to PT almost 1.5 years after my hip surgery because my muscles got very weak again, probably because I could not exercise without such pain in my psoas, so my body kept protecting and thus I got weaker and weaker (my backside). This is my theory, but it DOES make sense to me. I went for massage every 2 weeks because everything in my leg was so tight and stiff all the time. I had heard of this massage office near my home. I had to quit taking dance classes (ballet and modern) because it just kept hurting and not getting better. So, I went to massage therapists that were very kind and helpful, and I did feel better, and my psoas was released and relaxed, but never completely. My doctor sent me to a myofascial release group (they laid gentle hands on me, and it did not really help much) and then…then… I recently went to a massage therapist that does myofascial release (not the gently laying of hands, but another type, which releases the insertion/attachment points of my psoas and probably other muscles near my groin). It had lasting relief and was just what I needed. Stretching and massaging the body of the muscle did not seem to help as much as near the insertion/attachment points of the muscles to the bones. Finally, I am getting pretty relieved of all my pain. And my muscles are getting strengthened, and I am doing piriformis strengthening as well as other backside muscle strengthening, so this combination seems to really be doing the trick. It was a long process, and I do not know why it took so long, but I am finally getting there. I cannot wait to get back to dance classes, but I need to strengthen more. I hope this helps you, good luck to you. Basically, to answer your question, I found massage therapists from word of mouth. I hope my descriptions of the methods help you. I live near Boston - if you do, and need specific names, I can send them to you. Take care.
 
Hi @Dancer22 Thanks for replying and for your offer to recommend a massage therapist but I live in the UK .

I had my THR a year ago on 18th March so a year after yours but I didn't have an anterior but just like you I was convinced that I had an impingement.I have seen 3 Surgeons who have all reported that this is not the case.They diagnosed tendinitis of the iliopsoas after an ultrasound but the last OS changed the diagnosis to tendinosis which is a more chronic condition.Like you I found that the hip was very stiff and weak before I started the exercises and stretches.The worse stretch was extending my leg from a flexed knee lying down position it was so painful and it felt like 2 muscles were catching and scraping together.This move is much better now thank goodness.I now try to release the psoas first before stretching it by spending about 20 minutes in the Constuctive Rest Position and this had helped a lot.I have read 2 very good books which have been very valuable one called The Psoas Book by Liz Koch and the other called The Psoas Release Party by Jonathan Fitzgordon both Americans from a yoga background.Looking back I think I had psoas issues before the operation as I remember how the ROM was very challenged especially between having the arthroscopy and the THR.I probably attributed the pain to part of the arthritis at the time.I also twisted the groin at about 7 weeks but I seemed to recover from this after 3 months but the groin pain returned when I was about 9 months.The whole thing has been so frustrating as I imagined that I would get my life back and be able to go back to hiking and biking again but so far short walks on level ground is about my limit but the other hip is now arthritic so often this stops me from walking very far. I am so happy that you are doing so well can plan a return to your dance classes.How wonderful for you.Please keep me posted on your progress.
 
not so. I had my iliopsoas released arthroscopic and the proceedure was great. He released it from the lesser trochanter and did not go into the hip joint. This was the best decision I have ever made. I have had my left hip replaced now (different surgeon) and I'll be damned if my groin is killing me. I did have to have that one revised to put a different ball (to lower my left side a bit) about 8 weeks ago so I am not getting hasty, but I will not hesitate to do it again if that pain persists. By the way, that is the exact pain I have and I have had it before in my right hip before I had the tendon released.
 
To MarkC - I would really like to have the name and location of the surgeon who did the arthroscopic release of your iliopsoas tendon.

I am now *two years* out from my left THR, and still have groin pain whenever I lift my leg — getting in and out of the car, in and out of bed, and so forth. Putting on pants and turning over in bed are also tricky.

I exercise regularly on the elliptical and the exercise bike, as well as working out on a wide range of machines at the gym, and do some pilates. But I *still* cannot do a prone straight leg lift without excruciating pain. Until recently I would do five (very slowly, very painfully) with every workout, but all it did was irritate the groin and make my daily activities more painful, so I finally stopped the leg lifts altogether. There was just no point.

I had the "diagnostic injection" into my iliopsoas tendon sheath about a year ago and that did cause some improvement (which tells us the problem *is* iliopsoas tendon impingement), but what I *want* is to feel completely "normal" again. If the surgery you had worked so well for you, maybe it would work for me. I'd love to know more about it. Thanks!
 
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