THR Psoas / Iliopsoas tendon pain after THR

[Marls00]

SaraK, Jws., Layla, Minnie@5, Hip4life, Hello all -

I had my anterior THR in August 2019 and have had problems with my iliopsoas tendon since immediately after the surgery.
I actually think there may have been some issues prior to the surgery because when I started to walk sometimes, it would feel like something was crimped in my hip area and after walking for awhile, it would kind of unravel (that was the feeling), and then it would feel normal.
It wasn't terribly painful when it happened but was definitely weird and uncomfortable. I'm wondering now if it was snapping hip.

Anyway, after surgery the iliopsoas was very sore and I had terrible trouble lifting my leg. My quads in the operated leg lost a lot of strength, as though I hadn't exercised them for months. Very strange. The quads finally gained back their strength (took almost a year) but the iliopsoas is still a problem 2 years later.
A cortisone shot gave me relief for one month which was wonderful!

Imaging doesn't show any problem with the cup placement, or any obvious issue with my tendon rubbing on something. I guess either of those would be considered impingement.

It seems like the tendon was just traumatized during the surgery and hasn't recovered.

My surgeon is now recommending a full tendon release which I thought was only done when there is a cup overhang or other impingement, or for snapping hip syndrome. But he seems to think it's a good option.
At this point, I am worried about weakness and complications with a full release so I am looking at other possibilities, i.e., lengthening, partial release or a percutaneous tenotomy (injuring the tendon with fat needles to eventually encourage healing). Am also wondering if platelet rich plasma injections might help.

Anyway, I have a few questions for those of you who have had iliopsoas issues and/ or procedures done to alleviate the pain.

I have read some of your stories, which has been very helpful, but if you could answer some of these questions, I'd really appreciate it!

1. How did your iliopsoas pain manifest itself and how soon after your THR did the pain start? (for me, I have pain when lifting my leg, especially getting in a car, getting on my bike, sometimes rolling over in bed, sitting up in bed, pulling on my pants, lifting my leg straight up when laying down, and if I am walking for a long period without a break (2-3 miles) or standing for a very long time, it gets stiff and extra sore. But I generally have little to no pain while sitting, walking or biking).

2. Did you ever consider just living with the tendon pain and discomfort, or was it too intense to even consider that option?

3. If you chose to have a full release, what were your results?

I would also like to know your age, if you care to share that info! My surgeon finally admitted to me that the many successful tendon releases he has done has been for athletes or people younger than myself (I am 64).

4. If you had a procedure other than a full release, what was it and what were your results?

5. Do you feel that you had a clear explanation of why the tendon was causing you problems? (I am not confident that anyone really knows why I am having this pain! Seems to me that should be something they would want to know before they start cutting away tendons!)

Any other info you care to share would be welcome!

Thank you very much!

 

[Jockette]

@Marls00

I‘m sorry you’re still having this issue, and I’m sure the hip staff and members will reply soon.

By the way, I merged your newest thread with your original recovery thread, as we prefer that members in recovery have only one thread.

This benefits you because all your information is in one place, easy to find, and maintains a nice journal for you.

This also benefits our staff, as your information is all in one place, and we often go back through your thread for previous details, so we know what you‘ve been through which helps us advise you better.

So, please keep all your posts in this thread. If you’d like a new title, let us know what you want, and we’ll change it for you.

Many members bookmark their thread in their computer browser, so they can find it when they log on.
How can I find my threads and posts?

Best wishes on your continuing recovery!

 

[SaraK]

I had the SuperPath procedure on both hips (different times). The psoas can be a bit grumpy afterwards so we took it easy on leg lifts, etc in PT. In both cases, the psoas settled down within 2-3 months. With the second hip, I started having problems a couple of months later. Pretty much the same symptoms you're having. It started off low level but got worse and worse. I knew what the problem was but never could get my surgeon or the pain mgmt Dr to even really consider it.

Psoas impingement can be difficult to see on any imaging. The gold standard is a combo of the symptoms you've described and relief from the cortisone injection. I was told that some patients only need an injection every few months but that surgery is most often suggested when that relief doesn't last long (I only got a couple of glorious weeks).

I couldn't go on without the surgery. The pain was too much and I couldn't sleep in my bed because I'd wake with a huge stab of pain rolling over. My surgeon did the release at the groin and said that it effectively lengthened the tendon by 1-1/2 inches. He said even a small overhang (in my case due, in part, to slight dysplasia) can create an issue. Like you, I may have had some snapping hip issues beforehand. One explanation I've heard is that psoas impingement is more common now because of surgeons using larger diameter implants for better stability and less risk of dislocation and because the current implants are a full 180 degrees instead of 160 degrees (also reduces dislocation risk) so there is a greater chance that a slight overlap will occur.

I was 55 when I had the psoas release. In between my first THR 20 months prior and then, I went from couch potato to gym rat. I still have a bit less range of motion and have more difficulty lifting my leg above waist high, but it doesn't hurt except at the limits of my range of motion. I can walk a few miles with no pain after and even started powerlifting (or what passes for it when you're a woman in her late 50s).

Note - the surgery itself was a breeze for me. I had stiffness for a few days because of the fluids the use for arthroscopic but very little pain. Within a week, I was feeling better than I had in a long time!

Best of luck as you try to sort through this!

 

[Marls00]

@SaraK - Thank you so much for your response. I never heard of SuperPath and had to google it. Very interesting. If it's safe and effective with minimal complications, I certainly hope it catches on!

I knew what the problem was but never could get my surgeon or the pain mgmt Dr to even really consider it.

Same with me. Considering how difficult a time some patients have with that tendon after THR, you'd think the doctors and physical therapists would be more aware/open to acknowledge and consider patient complaints. But that's another conversation!

So you had a full tendon release and afterwards didn't have any issues other than limited strength and range of motion only in situations where it doesn't really matter much. Is that an accurate assessment? I am very concerned that I will end up in worse shape than I'm in now if I have the release. Once that tendon is cut, there's no going back. I think part of my concern is that I don't really have a proper diagnosis. Could I just have a traumatized tendon that hasn't healed? Or do I have mechanical impingement issue? No one can give me an answer. I'm seeing a doctor at HSS in 2 weeks and am hoping they will do additional imaging so we can once and for all know exactly what's going on.

Did your surgeon consider a partial release or any other less invasive treatment? (i.e., Platelet Rich Plasma)?

 

[Hip4life]

@Marls00 I only check in on BS occasionally now but will answer if tagged. Somehow I missed yours. I’m sorry you’re experiencing this ongoing painful situation. To clarify: SaraK had a partial release. I had a complete release. Yours and our journeys about this issue are very similar. I would still be happy to answer any of your questions as it relates to my experience if you’re still interested. At least know you are not alone.

I see you were to have an appointment here soon and if you have, how did go?

 

[Marls00]

@Hip4life Thanks for your response. No worries, this is the first I’m checking this thread in over 2 weeks. If you could share your experience with the full release, I’d appreciate it. I thought @SaraK had a full release. I like the idea of a partial much better. I have an appt at Hospital for Special Surgery in NYC next week to discuss my situation with one of their hip specialists.

 

[SaraK]

Mine was referred to as a release but technically a lengthening. Surgeon said effect was about 1-1/2 longer. Different surgeons/different procedures. Between @Hip4life and me, you can see both can be successful! I'm sure each school of thought has their view of the pluses and minuses. Good luck!

 

[Hip4life]

I was 62 at the time of my surgery. In summary, starting at about 6 months post THA: ongoing, recalcitrant pain in front of groin, especially with certain activities, as you described, diagnosed as iliopsoas tendonitis caused by slight overhang of the acetabular cup. Options were: injection, tendon release, or revision. Injection is both diagnostic and therapeutic. The injection only worked for 2 weeks but then they at least knew for sure that it was my tendon. Thus, I only ever had X-rays done.

I was then referred to an arthroscopic specialist who did not want to perform a partial release for various reasons I really didn’t get nor necessarily agree with. So I then decided to go with revision but my OS knew I really would like a different option. He then referred me to another arthroscopic specialist (outside his practice, no less) who did complete releases. That’s what this specialist recommended for THA patients to avoid some potential repeat surgeries. There would be little to no loss of strength. The recovery had little down time (I could return to work in a week) and required no PT. That was the option I took because I needed to be done with the pain and get on with life. This was now 9 months post THA.
Actual experience: surgery was about 30 mins. I was sore for that first week but that groin pain was finally gone. I took about 2 weeks off because I had a job where I was on my feet. I was able to ease back with a couple of reduced hour days. I was also able to get back to my regular activities and exercise regimen almost immediately using common sense. It took about 3 months to build my strength back up to my goals but not unexpected since it had been a long road of decreased activity before my THA in the first place.

I have no regrets. I currently only have minor reduced active range of motion: trying to lift my leg past waist level, or put on socks but none of this affects me in any significant way. I walk, hike, bike, swim, climb up and down banks to fish to my heart’s content.
Like Sara said. We both had good results. It’s ultimately up to what your surgeon can offer and if you’re comfortable with that and the doc performing it. Let me know if I can be of further help. Best wishes and keep us posted. Blessings, Pat.

 

[Jws.]

@Marls00 , @Hip4life, @SaraK
Sorry, I drop in once in awhile to see if I can help..
I am a direct NY'er and have researched the Psoas tendon release and as you can see had the full gamut of releases by different OS's so I can give you my subjective take.

Marls,
You posted this about a week ago...This is the classic symptomology of a Psoas tendon problem.
"have pain when lifting my leg, especially getting in a car, getting on my bike, sometimes rolling over in bed, sitting up in bed, pulling on my pants, lifting my leg straight up when laying down, and if I am walking for a long period without a break (2-3 miles) or standing for a very long time, it gets stiff and extra sore. But I generally have little to no pain while sitting, walking or biking)."

I had this for three years and it was the WORST. Most OS's don't want to deal with this (your OS who said this is an "uncommon event" from THA is not accurate.)..Anyhow , I wont get into my frustration with the OS's who dont want to deal with soft tissue complications. The Psoas Tendon impingement is REAL and is definitely curable i.e Pat (@Hip4life and @SaraK ). and there is no reason IMHO to avoid this surgery at all. (yes it has the usual risks, but it is so quick and the downside is so minimal compared to the upside, its a no-brainer. )..two caveats I can give you . I had the partial lengthening at HSS and it didn't work for me , it WASN"T ENOUGH RELEASE..so a wasted operation with all the attenuated costs, both emotional and financial. I then had the FULL RELEASE with Pat's (@Hip4life ) surgeon and it was and he was an absolute blessing. (so was PAT) What a great guy!. Anyhow, I still am having some complications but much better than before.
If you got total relief from the cortisone shot , the surgery will work for you and the way you felt from the cortisone is the way you should feel from the surgery (yeah I know amazing right..!)..I had absolutely NO weakness in my leg from the first psoas release at HSS but I had no relief as well !. I definitely had weakness from the FULL RELEASE AT THE LESSER TROCANTER (second psoas release) but could walk. (the weakness gets better and you will be left with residual weakness..i.e putting on your socks,shoes, etc. I would go with the full release every time..(howevere sara k had the partial and it worked for her..If I was going to do it all over I wouldn't risk the shot , I would go with the full release at the lesser trochanter..(very little risk of infection ..(you're not going near the prothesis, no risk of instability (you're not going near the prothesis, etc, etc.)..these were the two things I was most concerned about and in this surgery they are a non issue..(no more than any other surgery (infection).

If you have any other questions just dm me...GET IT DONE >>>DOWNSIDE IS MINIMAL>>UPSIDE can be WONDERFUL>> ASK PAT OR SARA...BEST JWS- put this behind you- get your life back!

 

[Marls00]

@Jws. @Hip4life @SaraK Hi all and thank you so much for your responses. I feel like you are the only 3 people on the planet who understand what I'm going through! @Jws. when I read your post last night I was ready then and there to sign up for a full release. I will DM you to ask what surgeon you and Sarak used at HSS.

Here's my update:
Saw Dr. Gausden, hip specialist at HSS, last week. She said my xrays (taken from different angles) show NO SIGN of cup overhang. Others have told me the same. I asked if it was possible I could have slight overhang that is not showing up in the imaging and she said: very unlikely. I asked if I don't have cup overhang, what happened to me? Was my tendon just terribly traumatized during the replacement and hasn't recovered? She gave a very non-commital "yeah, it's possible" kind of answer. She then said she thinks it's possible that another cortisone shot could push along the tendon's healing and get me back to normal without surgery. (A shot I had earlier this year worked for one wonderful month.) She said if it doesn't give me lasting relief, then I should consider the release as an option. For the release, she referred me to arthroscopic surgeon Dr. Nwachukwu at HSS. I asked about full vs. partial and she said she doesn't think they do partials.

My biggest concern is this: if I do not have cup overhang, could there be something else going on with my anatomy causing this issue with the tendon, and, if so, how do we know that releasing the tendon won't make things worse? This is something I will probably never get an answer to, which worries me. (I will ask the arthroscopic surgeon this question but would expect a typical non-answer.) I do have some lower back issues and also scoliosis - not serious, but some issues -which I have read can sometimes impact THR outcomes. So how do I know that they won't cause issues with regard to a tendon release? These are the questions I research to no avail.
If I knew I had cup overhang as you all did, it would be much easier for me to commit to the surgery, but that's not the case.

That said, I am 64 years old, very active with serious longevity in my family and I can't imagine living like this for another 30 years! It's true I can walk, bike, hike (not climb though) without any trouble but simple activities of daily living that engage that tendon - of which there are many - cause me pain. And I'm sick of it!! So at this moment, I am finding myself warming to the idea of going through with the surgery. Hearing your stories is giving me hope!

Regarding residual weakness after the release, you've all painted an acceptable picture and perhaps I need to put that concern out of my head. The fact is, I have trouble lifting up my leg in many situations as things stand now, so if I still have some trouble after a release but the pain is gone, that would definitely be a win.

I have read that releases are done from either the lesser trochanter or the central or peripheral compartment. I assume they are talking about full releases. The study I read suggests the lesser trochanter have better outcomes, but they say fewer surgeons are familiar with doing the procedure from that location. Though I'm glad to hear there are surgeons at HSS that do it. @ saraK, and @Jws. do you know from what location your partial release was done?

Thanks again, all, for your input. I can't tell you how much it helps hearing from others who have been through this!!
Marlene @Marls00

 

[HelenaM]

@Marls00
I experienced some pain that became very noticeable at about 10 mo. after surgery. It may have been triggered by some side leg lifts etc. assigned to me by a pt. The pt said I had irritated my hip flexors, and my internist said I had tendonitis in that area. She encouraged me to use heat, and I felt that that did help over a few weeks (in her opinion, the heat brings blood to tendons so that they can heal). I though I might have an impingement, but was told I did not based on X-rays. I did have meralgia parenthetica, but the hip flexor issue was different. Dont know if the heat ( and maybe a little rest of the area) would help you, but I just wanted to mention it. Hope your symptoms resolve.

 

[Hip4life]

@Marls00 Oh, Marlene, this can be such a challenge to sort out, especially if there is no clear cut answer. If I hadn’t had the detectable overhang, I think I might have tried another cortisone shot, as it was an option offered to me as well. As your OS has suggested, if this one really doesn’t give you the relief, there is always the surgery. As Sara previously said, sometimes imaging doesn’t show an obvious impingement. Some of your symptoms may be caused because that tendon is so angry and doesn’t get a chance to quiet down. Perhaps just being inflamed may cause it to rub on pelvic structures more than it normally would. People can even have that without a previous surgery (e.g. a “snapping hip.”)

Should you decide on surgery, you can ask the arthroscopic specialist about what approach he/she does and why. They would also be the best source on how your back issues/scoliosis might weigh in. My understanding is that the partial release (cutting some fibers to release the tension, essentially lengthening it a bit) is up by the capsule/greater trochanter where that end of the tendon was aggravated by the THR surgery. A full release is at the lesser trochanter where that part of the tendon is completely cut from the bone releasing the tension. My arthroscopic OS explained he did the complete for post THR patients to avoid the chance that a partial might scar up back to a shortened, tight tendon.

So that’s my take on your visit. It just comes down to what you’re ready for at this point since the OS didn’t have any definite recommendations. Unfortunately, that seems to be the confusing, shared reality for us post THR, IP tendonitis cases. In the meantime, we’ll be here for you as you try and decide what’s next. Keep us posted. Pat.

 

[HelenaM]

@Marls00

There was forum member who had experience with Psoas tendonitis awhile ago. I don’t think she has posted in awhile, and I don’t think she posted about her outcome, but you might want to read her thread for information about her experiences. Her name is Mer123.

 

[Mojo333]

Click HERE for link to Mer123 thread.

 

[Jws.]

@Marls00 @Hip4life @SaraK
Here's the cliff notes ...partials are done at the central compartment and a little bit lower...they do not do total releases there only at the lesser trocanter. "partials" are not really partials but "lengthenings" and they don't lengthen that much... (mine wasn't enough...night and day in results between lengthening and total releases...there are some that it "just works perfectly " for a lengthening like sara..but mostly lesser troc total releases cover all the bases so why risk the chance of a "do over" with a lengthening...their theory on lengthenings is that it is closer to the "groin " pain which doesn't quite get it as the release from the lesser trocanter releases all the way up so it will get the groin pain as well ....

at HSS I had an ortho (I'm blanking on his name -but he only does lengthenings...his last lesser troch was 11 years ago..) I used Dr. Burt in Nebraska for the full release. (pat and sara can tell you who they used...I dont think sara used anyone at HSS).

The take away here is that there is very little risk at total release at lesser troch and a heck of a lot of benefit if not a cure for that pain that we all had for years... (12 minute surgery!) (P.s. plp, and all the regenerative stuff doesn't work for this so don't let them mess with that..it will just waste your $$$, time and emotions!)