[Psoas Tendon Release] Psoas Impingement After THR

[sfield27]

Total Hip Replacement 4/01
Partial Psoas Release at the Lesser Trochanter 5/08

I am Australian and 57 years of age, I had a right total hip replacement in January this year due to hip dysplasia and a torn labrum, and I also had a small amount of arthritis. The surgeon I chose came highly recommended at a private hospital using Mako Robotics to assist with hip placement.

On day four, when I was due to go home, I could not empty my bladder and had over a litre of urinary retention. I needed to be catheterised again, develop sepsis, be treated with antibiotics, and then train my bladder to work again. At this stage, I thought my hip was fine and could do as expected over the next weeks but was fatigued by the big infection. I walked and gently did 1-1 pilates as rehab exercise, used ice and was given the all-clear by my surgeon at 6 weeks. I was walking well and eager to get moving and not taking any painkillers.

I was excited to return to my pilates class and start walking further. By 8 weeks, I was in pain and stopped all activity and headed back to my GP because I had pain behind my knee and in my groin. Sent for a dopler, which was clear and then to a physiotherapist who decided to tell me that it was my back that was hurting and that the surgeons probably fixed the wrong thing. The doctor checked the MRI back perfect.

The pain continued: putting on socks, getting in the car, standing, sleeping, a continual deep ache and sharp if I moved. The pain made it hard to sleep, and I became miserable. I returned to the surgeon as I noticed that my hip would painfully snap, and I suggested iliopsoas impingement. It took another six months for the surgeon to agree that it was psoas impingement as he had never previously had a patient with it.

I had two cortisone shots and the one into the sheath worked. A CT revealed that I have a 10mm overhang of the acetabular cup where the psoas tendon is. My surgeon is the head arthroscopic surgeon at the hospital and he did the release at the lesser trochanter about six weeks ago. My pain is better and I can walk on the flat a bit better but the deep ache is back and I cannot put on my sock struggle to get into the car etc.

I am going to get another cortisone shot into the sheath as the tendon seems sore and cranky. My next choice is a second release of the cup or to have the cup revised. I learnt yesterday that you can only weight bear at 20% for six weeks after the cup revision. Also, as I have dysplasia and a short socket the bone loss on the replacement could be substantial. I need to get out of pain and get my life back. I have limited my movement and cut back on my work by 50% so I am at home as I could not get myself to work and stand as required.

Any advice is greatly appreciated because at this stage my hip replacement has been a disaster and my desire to walk and live pain-free has not been achieved.

sfield27

 

[Jaycey]

@sfield27 Welcome to BoneSmart! That new hip has certainly seen lots of activity since your THR.

At only six weeks out of your release. It is a bit early out to assume this procedure didn't work. Are you icing and elevating that op leg?

Several of our members have had experience with this. I'm sure they will be along to give you their advice. I believe my colleague @SaraK had Psoas issues post THR.

 

[sfield27]

Yes, I am icing, elevating and resting. I have six more weeks until I see the surgeon again. My concern is that I was better at ten days than 42 days. I will be interested in other comments as you actually don't meet others with the same condition. My surgeon has done 54 releases this year and is not that positive it has worked.

 

[Hip4life]

Hello @sfield27 I am so sorry that you are still dealing with pain and limited ROM. It is a very frustrating place to be when at this point in time, you had really expected to be back to your life. I have lived this scenario but my solution was a bit different. I also had impingement from a cup overhand and, after an injection that was only a temporary fix, was offered revision or tendon release. Trying to avoid another major surgery, I was referred to an arthroscopic specialist who did a complete release at the lesser trochanter. He explained that he preferred to do this for all of his post THR referrals as it eliminated the possibility of a partial tenotomy not working: not enough of a release, scarring shortening the tendon again, etc., thus needing additional surgical intervention. He further expounded that other muscles would "fill in" for the IP and that patients experienced little to no on-going strength issues. I found that what he said was true. I do have some minor ROM deficit that doesn't limit me in any significant way but can't necessarily relate all of that back to my release.

In my research before my release, there was literature that analyzed the success of tenotomy versus revision and the role the amount of cup overhang had. Ultimately, the decision as to which was preformed was always referred back to the OS and the patient. Only they specifically know the details of the anatomy and any other medical issues that could influence outcome. However, given your concern for avoiding revision, a complete release may be a good option for you as it basically eliminates the culprit to any impingement. Something to definitely consider. Please let me know if I can be of further assistance.

 

[sfield27]

Thanks for taking the time to share your history, and I am excited to hear you have your hip back-that it is possible! I got some cortisone yesterday under ultrascan guidance, and the tendon remains very tight over the jagged edge of the cup. I have been referred to the most experienced release doctor in the country and will travel to another state for his opinion on the best options moving forward.

It was bliss for two hours while the local was in my hip, and I could actually get my leg into the Uber ride home without physically picking it up. The partial release doesn't seem to have worked, and I have added in glut pain, but the extremely painful snapping has not occurred after the release. Please, surgeons, measure carefully and do not put in cups that are too large as psoas impingement is the result, which is difficult to fix.

 

[PolarIce]

Would you be able to get a second opinion just to ask questions and confirm that everyone in fact looks good?

 

[sfield27]

Yes, the surgeon has handed all my records and reports to another very well-respected surgeon in Canberra, which is another state about four hours' drive away, quicker if you fly. I will travel and get his opinion, he actually trained in Canada and is the only surgeon who recommends a second psoas release before cup revision.

Thanks for taking the time to reply.

 

[Hippie Chick]

Hang in there!

 

[SaraK]

@sfield27 - I'm so sorry to hear you're having issues with the psoas. It really is more common than many surgeons seem to believe. It took me until almost a year after the THR to finally find a surgeon who actually looked at psoas impingement as the culprit despite me having all of the classic signs. When he pointed to the x-ray and started showing where the psoas was, I immediately blurted "psoas impingement" and he laughed and said I'd obviously done my homework.

My original surgeon had referred me to a pain management specialist who insisted it was my back (at the point the psoas inserts into the back). In the meantime, it just got worse and worse.

Like you, I had some dysplasia and was told by the new surgeon that it was the primary contributor to the cup placement being off (I still think there was a bit more to it because my range of motion in that hip has never completely recovered).

My surgeon did a release (partial release) at the groin. That gave it some relief at the site where the rubbing was occurring. That did the trick for me from the pain standpoint. It is harder to lift that leg than the other because there isn't the same tension in the psoas but to be able to lift without pain is incredible.

Whether you should get a second release or a revision is something none of us can say. Only an experienced surgeon looking at your records and scans is going to be able to answer that question. Two weeks non-weightbearing (if that is what the surgeon says - my research told me I was going to be non-weightbearing after the release but the surgeon actually let me go out dancing the same day as the surgery) doesn't seem like much if it gets rid of the nagging pain you're experiencing.

 

[Veronica Lodge]

Dear @sfield27

I really feel for you after reading your thread.

We go into this hoping it is the answer to our prayers and it is so distressing when you continually have to overcome obstacle after obstacle.

I am 48 years old and also have mild hip dysplasia with a shallow socket.

I had a hip arthroscopy 9 days ago and labral tear repair but have been told that I will need a hip replacement in 5 to 8 years so I am behind you by a few years but potentially on the same path.

I live in Melbourne, Australia and had surgery at Mitcham Private Hospital.

I wish you well and will keep an eye on your progress.

Veronica Lodge

 

[sfield27]

Thanks for your replies, Veronica & Sarah K. It is helpful to share and hear other experiences. I have spent the evening filling out forms and sharing all the scans, MRIs & CTs with the second and third-opinion surgeons. Was thinking this hip needs its own personal assistant.

Best wishes for your recovery Veronica and when you need the replacement, have a serious conversation about the cup size with the surgeon and how it will work with the shallow socket. I didn't even know to ask this and I think it may have assisted with a smaller cup and avoidance of these issues that have controlled my life for the past year.

Sharon

 

[sfield27]

I am updating my details after experiencing 300 days of pain and the inability to even walk around the neighbourhood. After speaking with three surgeons, all recommended a second tendon release as the safest option. I am booked for surgery on 30/10/23 for release at the level of the joint. The surgeon will look at the overhang on the acetabular cup, which is currently showing as 10mm where the psoas tendon is on CT.

I have also completed further X-rays and another CT, and this has been sent to be checked that the pain and lack of movement is not component on component impingement. I am very much hoping that this signals the end of this journey and the surgery is successful. It will involve at least eight hours of travel, an interstate stay and a second driver etc to accompany me. Would love to hear from anyone who has had a second release and had success.

Thanks Sharon

 

[Mr.fun]

Sounds like your surgeon is not being completely honest. I say this because he has said to you that he has never seen iliososas impingment before. but admits that he has done 54 tendon releases this yr. He seems to contradict his message. Also keep in mind that if he would have done his job properly. Meaning... positioned your cup properly when he did your surgery. There would be no 10mm over hang and no iliosoas impingement. I believe I am dealing with the same issue.

 

[Hip4life]

Since there are many anatomical differences with individuals, there are a few different strategies available to surgeons in prosthesis placement to accommodate those differences. It's a judgment call and sometimes it might not work out as well as all would have hoped. Unfortunately, it can be a painful situation to deal with, a difficult one to pinpoint, and a frustrating one to correct, as you well know. Yes, tendon release carries fewer possible complications and risks. I am sincerely hoping the second release brings you the relief you are seeking. The road has been long but remains one step at a time. Have courage and hope and know you are not alone. We will be anxiously awaiting your update after your surgery. Blessings as you wait and as you travel, and through your surgery.
@sfield27

 

[Hippie Chick]

Hang in there!

 

[sfield27]

Dear Mr fun,

To clear up the confusion, the surgeon I chose for the hip replacement is also the only surgeon at the hospital I attended who can release a psoas arthroscopically. He has completed 54 surgeries to release the psoas for other surgeons. He is ultra-careful and uses all the modern computer tools to plan to avoid psoas impingement as he knows how miserable a condition it is to have. I am his only patient who has psoas impingement to date. He is very upset to have caused it, and as Hip4life has stated, we all have different anatomy, so even with the best intentions, psoas impingement runs at approximately 4%.

I needed the THR as I had hip dysplasia and a labral tear. I am also a firstborn female, which puts you at a higher risk of hip dysplasia and, as a result, psoas impingement is more likely. I am just hoping for it to be fixed. The other feedback I have received from the three surgeons is that it may or may not be a 10mm overhang, as the CT scans are not always accurate. I hope it is less, and the second surgeon will get eyes on it as part of the arthroscope. I hope it is less because the limited research shows that an acetabular cup overhang of less than 8mm responds to tendon release over that, and the cup needs changing.

I wish you well on your journey to healing and full function.

 

[Spongebob]

@sfield27 - I'm so sorry to hear you're having issues with the psoas. It really is more common than many surgeons seem to believe. It took me until almost a year after the THR to finally find a surgeon who actually looked at psoas impingement as the culprit despite me having all of the classic signs. When he pointed to the x-ray and started showing where the psoas was, I immediately blurted "psoas impingement" and he laughed and said I'd obviously done my homework.

My original surgeon had referred me to a pain management specialist who insisted it was my back (at the point the psoas inserts into the back). In the meantime, it just got worse and worse.

Like you, I had some dysplasia and was told by the new surgeon that it was the primary contributor to the cup placement being off (I still think there was a bit more to it because my range of motion in that hip has never completely recovered).

My surgeon did a release (partial release) at the groin. That gave it some relief at the site where the rubbing was occurring. That did the trick for me from the pain standpoint. It is harder to lift that leg than the other because there isn't the same tension in the psoas but to be able to lift without pain is incredible.

Whether you should get a second release or a revision is something none of us can say. Only an experienced surgeon looking at your records and scans is going to be able to answer that question. Two weeks non-weightbearing (if that is what the surgeon says - my research told me I was going to be non-weightbearing after the release but the surgeon actually let me go out dancing the same day as the surgery) doesn't seem like much if it gets rid of the nagging pain you're experiencing.

Hi im reading your thread about psoas impingement could you possibly tell me what that feels like to live with day to day what pain it causes and where if you don't mind

 

[SaraK]

For me, it was a sharp stabbing pain in the groin when I lifted the leg or pushed off on it. It also developed into a constant burning pain in the same area with stabbing pain on any activity. It started mild and just got worse over time.

Other people may have a different experience, though.

 

[sfield27]

I am now two weeks post-recovery from a second psoas tendon release at the level of the capsule/joint. The surgery went as expected, and I could bear weight straight out of the theatre. I can now lift the leg a little and feel I have a better walking gait. Unfortunately, the tendon feels tight and very painful over the past two days. I am back to resting and ice. I have only been walking around home and small distances as advised by my doctor. My surgeons say they will only know if the release has been successful after 6-8 weeks. I can feel the sharp metal of the cup, and the CT shows an overhang. If this doesn't work it is a bigger surgery to swap the acetabular cup.

 

[Jaycey]

@sfield27 Early days! You need to give this time to settle. Rest and ice are a good strategy. Are you taking anything for pain?

You will notice I moved your post to your recovery thread. You will get more input from our members here.