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Discussion in 'Hip Replacement Recovery Area' started by Jws., Apr 6, 2018.
I don't believe I ever received your xrays
@Josephine @SaraK. I have gone back to my four OS and internist and they "reversed" on their opinions. (what else is new?).
The one "sage" doc went from trochanteric impingement to psoas impingement and the way he would treat it would be to OPEN the posterior area and free the tendon ALL along the lower trochanter. He says that there are other muscles there and the "freeing of the whole tendon" - "full release" would not make the leg weaker.
I have read up on tenotomies for the last two days and all have said that the idea of a full release is never a good idea, that a multiple cut or fractional release is the way to go. They also indicated that an open surgery for the tenotomy is not a good idea rather it should be done arthroscopically (i.e.less risk of infection, dislocation, etc.) and the fractional release (lengthening) will eventually allow the tendon to grow back and you will not lose much muscle power in that leg. He did agree that a cortisone shot in the psoas would be a good diagnostic tool to see if it is actually psoas but said he was not hopeful it would take away the groin pain for more than a week.
My primary OS surgeon without much manual testing issued a prescription for a cortisone shot in the psoas and came to that suggestion as well - psoas impingement. He said there is a possibility the cortisone shot could be "a one and done".
The third OS I saw came to the psoas impingement as a possibility and said no harm in taking the cortisone shot as diagnostic as well. He does do arthroscopic psoas tendon fractional releases and he indicated "I would be real lucky " if the cortisone shot worked for more than a couple of weeks but there is always a possibility of a shot being "one and done".
My fourth OS who I actually scheduled for the psoas shot in two weeks under ultrasound said there is a possibility of "one and done" as well but said after that arthroscopic fractional lengthening tenotomy would be the last chance.
I talked to a very credible patient who had the multiple cut arthroscopic tenotomy done and she was generous enough to spend time with me and her result was great. She indicated that it should be a fractional release and the cuts should be "proximal to the acetabular cup near the lesser trochanter.
@Josephine my concern is this; before the diagnostic cortisone shot this Friday - I have read that there is a OS doc who does these regularly and he has indicated that the cortisone shots given with u/s don't work and that the shots given under fluroscopy give 70 % accuracy and pain relief.
Jo I have two questions;
1. Do you or anyone on the forum know whether the fluroscopy shot is that much better than the u/s and should I only do it under fluroscopy? If I did it under u/s this Friday I would have to wait three months before I could do another one under floroscopy.
2.IS it realistic that the cortisone shot could be a "one and done situation"?
Any help on this would be greatly appreciated. Any other thoughts on the risks and dangers or suggestions on tenotomy would be welcome as well
thank you all.
To be honest, I am alarmed at the thought of you having a full release for this problem. Certainly as a first shot scenario anyway. I've never seen such a procedure done, not ever. And I think the recovery could well be equivalent to the original hip replacement! Horrendous!
I once worked with a great ortho surgeon who used to say "always use the little guns first"! And he was right! And then work your way up the bigger treatments.
So in terms of guns, I'd list them
1. cortisone shot - maybe repeated in 3 months
2. closed (meaning no incision) or arthroscopic tenotomy with or without u/s or fluroscopy (which is actually just xray using an image intensifier which shows an active screen shot rather than a static one)
3. closed or arthroscopic release or Pie crust (dry needling) release
4. thinking time
5. more thinking time!
6. full release - perhaps, maybe, maybe not!
I've had cortisone shots in my shoulders every 3-6 months for years and they do work pretty well but they don't last forever. But I also had a cortisone shot in a right trochanteric bursitis twice and both times it was a 'one and done' situation.
Whilst reading though your thread, I cam across a post where I asked you for your xray which you appear to never have supplied. That would be helpful, you know
@Josephine..I agree from all I read I will not be goining in at any time for a FULL release.
In reference to your "little guns list"...I agree whole-heartedly...
I am starting off (hopefully finishing) with a cortisone shot to the (hopefully) bursa of the psoas.
My major issue here is the OS wants to do it under ULTRASOUND and from all I read Ultrasound shots can miss the mark and not relieve the pain, whereby shots under FLOROSCOPY are much easier to see and have a 70% higher rate of success. I need a "true" diagnostic shot that can tell me if it is psoas or not and if U/S is not accurate I may never know if it is my psoas or not.. Josephine , is the above true..this is important .. as I can cancel the shot using the U?S and there is another qualified OS here in LA who does the shot under floroscopy.. I like the OS doing the U/S shot but not that much that I get a poor result..Pleases advise on this asap as I am scheduled to get the shot friday.(along with a shot again (wore off) in my trochanteric bursa).
No one suggested "pie needling" ...Is that a surgical procedure done by OS's or ?? do they do it to psoas as well as IT band? does it work well to lengthen the psoas muscle? Is it relatively simple like acupuncture?
Are you saying "thinking time" , that I just give this more time (it's been 12 months post op, having constant groin pain sitting now and when walking)...ABSOLUTELY MISERABLE...
A unique thing happened yesterday, I had my PCP measure from bone to bone the way you described and he came up with a 2" lld (a lot right)whereby my right operated leg was shorter...two of my other OS's from time to time also dx a "short hip" as the problem , and a 2-3cm difference caused by the surgery and my natural pelvic state which was slightly shorter but increased with the surgery.
As a result I went to my podiatrist (friend) who said it wasn't 2" (says thats a lot) but did give me cloth lifts (1/2 inch) to put in my shoe about half inch. I walked with the lift yesterday and my pain was better , my gait was better...could the shortness have been causing my groin pain and could this be the "miracle-smallest gun cure ever ) to alleviate the groin pain from whereever (psoas, it ,) and give me relieve.. (from my lips...)..
Please advise ...I will send you the xrays as soon as i figure out how to or have my it guy do it...(all my OS's looke at it and said it was fine except the one who said my primary OS didn't leave enough room with the ball and lier and that's structurally causing the impingement...
Thank you for always responding so quickly ..you have been a g-d send..Jeffrey
Anyone else who may have suggestions please reply...
See if this helps -
Hope you have a good day!
My surgeon sent me to a pain management specialist who kept thinking that the sacrum was akilter and or the two sides of the pelvis were tilted in different directions (pelvic torsion) and that this was causing the psoas to spasm and cause all of my problems. None of the therapies her PTs did (including giving me a heel lift to use for a while) helped me (actually caused more pain) and one PT told me the imbalance was very slight and in the range of normal. The back and LLD are definitely items to rule out before surgery. My injection, that diagnosed the impingement, was under fluoroscopy and into the tendon, not the bursa, since an MRI had ruled out psoas bursitis. My injection was done by radiologist not surgeon. I asked about U/S v fluoroscopy and she said both could give good results by someone trained and experienced and more an issue of which method the person doing the injection was comfortable with. Josephine might have more/better info, though.
The correct term is pie crust OR needling. Did you look at the article? As far as I know its use is pretty wide spread.
I would agree that 2" is a lot! Probably the biggest LLD I've heard of! But you seem to have had quite a good result from the lifts.
@Josephine....So here is where I am at - I am thoroughly despondent. I am 13 months post op THR. Have never been able to really have one day without some sort of pain.
As you can see from previous posts, many well known OS's and different theories. I am presently having groin pain, I limp and I feel pain now in the butt area right by my "posterior" scar when I walk (scar is fine and no infection).
I have no pain when I sit, sleep, (except still have difficulty sleeping on the unoperated side and bringing my operated leg over). But generally no pain sitting, sleeping. I have no infection, no loosening, no HO, no hernia, no major identifiable problems except some sort of soft tissue problem.
Have "catching pain" in hip flexor (psoas) when I get up, and when I walk. My OS's have narrowed this down (they think) to a psoas impingement problem. I am scheduled for a Psoas cortisone shot ultrasound guided on April 5th. I have researched the shot and the possibility of a tenotomy after if the shot doesn't relieves the pain.
I have not seen in all the research a cortisone shot in the psoas tendon to fix the problem permanently. Would love to hear that that is a possibility. I know Josephine had the TB shot and it resolved on its own forever but I haven't seen a psoas shot doing that. Would love to know I am wrong.
I have groin pain getting in my car, sitting and laying down (burning feeling not pain, (1-2)-just annoying and makes me nauseous). I can go on a spinning bike for an hour, no pain. After, I get up from sitting (catching pain) and stretch and most times start level walking, can walk for 3 miles, no pain.
But I don't have significant pain going uphill or steps. (Psoas generally has these symptoms). If you press on my psoas it's tender and pain. Is it my psoas?
Roller coaster good walking with no pain and other days pain in groin walking, limping. Can't figure out how to get rid of the pain.
Talked to sarak and she thought tenotomy very helpful.
Talked to midea and she said she "uniquely, out of the box" had her psoas stretched and actually cured by just sitting on a horse and horseback walking twice a week?
Yesterday I took one Advil and two Tylenol yesterday (I haven't been taking ANY meds before) and yesterday I could walk pain free again and just tight?
@Josephine The last post was convoluted. Let me be clearer. Yes I am thoroughly despondent. Can't get rid of this groin pain and when I try to put pants on (when I pick my operative leg up and it's in a reverse L trying to put foot in pants, there feels like a piece of wood is in my hip, pain level3-4. Slight pain in groin when getting in car 1-2, pressure in groin going uphill 1 or steps 1, no pain sitting (sometimes slight "burning" 1, ), can't put socks or shoes on, "catching pain in hip flexor when I get up-pain 2)...walk it off couple of steps ok, no pain at night sleeping. That's where I am basically. No major pain but when all of these minor pains converge, horrible day, limp and can't walk.
All OS's have diagnosis now (really given in) to psoas impingement. I will have the cortisone shot on April 5th. I have read up on tenotomy as most info says shots will only give temporary relief no longer than a couple of weeks by most accounts. Most effective method I have heard from sarak and others are a "nick" at tendon by acetabulum or fractional and multicut release.
So here are my concerns. Please advise, help, thoughts???
Seen OS's varied opinions on (arthoscopic) Release
1. Some say minimal risk of dislocation if "nicked " by acetabulum. Others say there is risk of dislocation.. Which is correct if anyone has info or knows?
2.Most Os say the recovery and arthoscopic surgery are relatively simple ?
3. Most say it will relieve your groin pain (THANK God) but you will have weakness for 6-12 months in operative leg but not significant. Will be able to drive, just won't be able to lift your leg up to your hip for awhile but you will be able to walk up steps, uphill, etc..
4. risk of infection-minimal
5. Since I have very little discomfort walking uphill, or even on steps, but do have slight pain1-2 getting in car and restricted ROM (main problem), is it my psoas?
I am a big guy, powerful, blackbelt in Martial Arts and did that for 20 years. Ran 6 marathons, and did spinning for 2 hours before the surgery and did not have groin pain or bone on bone prior to surgery (that's another story).
My question here is my thighs and calves and muscles were strong as heck prior to the surgery. I have read that very strong guys after THR, because of the difficulty the OS has in dislocating the hip during THR, have a much longer recovery period sometimes as much as 18 months. Could this be the case.
6. In addition for the last two days I have taken 1 Advil, and two Tylenol and it has significantly reduced my pain, and increased my ability to walk (no limp) and slight to no groin pain. (I have not taken much of Advil or NSAIDS during the 13 months post THR. I am not clear of this point
7. Does the Advil reduce the inflammation therapeutically (like cortisone) and if you take it for a significant period of time could you reduce the psoas inflammation so that it would resolve?
Please respond with any help you have. This has been depressing as heck and I am at my wits end. (I avoid going into work, dinners out, my grandkids..i.e a normal life.
Thanks for your help all.
@Josephine ..will send you the xrays...(nobody sees anything wrong with the xray) but maybe you will ppick up something.
Actually, I was told that some people (many people?) are able to get full relief from the injection. Some are "one and done" and some just need to repeat every few months. Others, like me, don't get lasting relief and have to look at the tenotomy.
At this point, I'm about 2½ months out from tenotomy and have been able to lift my knee to hip height (i.e. femur parallel to ground). I've been able to do that for at least a month. Anything higher, I need to use my hands to help. I have the ability to do typical "day-to-day" things but will need a few months of PT-type exercises to get the more unusual motions, like lifting leg above hip height.
Good luck with the injection. Hopefully it will bring good and lasting relief and you won't need more than the occasional injection. My spirits were flagging as well at your stage. I was frustrated - especially since I was fairly certain of the diagnosis but my original OS and the pain management doc he sent me to just weren't listening. Even though it didn't work very long for me, the injection lifted my spirits because it confirmed the diagnosis and showed us the path forward.
Sara you are the best. Your answers are clear and informative and UPLIFTING. There is light at the end of the tunnel.
Let me know as you progress. Hopefully I will get relief from the psoas shot and will be on my journey to find the "right" doc to do the release. Boy am I looking forward to that process . May have to end up in snowy St. Louis after all (never was there ...looks warm and cozy from Judy Garland's " "Meet Me In St Louie". Thanks again, hoping for a "one and done"
So Sorry to read of all your pain and discomfort; I feel for you.
I have not gone through anything like you have, but I did have psoas issues at 6 weeks post op. I had the cortisone shot, and it resolved it permanently. So, yes, every case is different, but I just wanted you to know that it is possible. I am now 9 month post op, and rode my bike 76km yesterday pain free on operated / injected side.
Ps: but waves of blue murder today on the left (as yet) unoperated / injected left side.
So do you need my help still? Seems like Sara has met all your needs!
@Josephine..I need definitely your help...groin pain is worse..
You said in a past post you don't recommend psoas release's...rather series of cortisone shots..
Could you please help me with the post I wrote..above...ty..
Just teasing! Post me the xrays and I'll see what's what.
I wonder if some of the confusion regarding a release (which you might not need) is definitional. Josephine can correct this as necessary, but a "release" of the psoas could be the complete detachment at the trochanter which my surgeon said would result in much greater weakness. My surgeon also referred to my procedure (which is essentially what Josephine referred to in her second alternative) as a "release" but full connection of the muscle remains because the tendon is cut (and maybe not all the way through) at a point where there is substantial muscle connected all along the tendon. Just as with a series of nicks, this causes the tendon to be lengthened (and he said tendon would grow back in this elongated shape) rather than obliterated.
I had read Josephine's prior post as not recommending the "obliteration" type of release as I've seen her posting in favor of the microcuts or similar lengthening procedures on other threads.
@Josephine..here are my x-rays ....let me know what you think...(I don't think you can see psoas impingement or tendinitis on a x-ray ..but I'll leave that to you)...ty for looking at them...
@Jws. I edited your x-ray image to remove any personal information and reposted the thumbnail for Jo to look at.