What's really going on?

I have been asking myself for months now what is really going on in my body? What's really causing all this pain? I visited another doctor and I got another answer. My chiropractor believes that all of the symptoms I've described, including the clicking and stiffness in the hips, could be explained by muscular imbalances and tightness in my hip and rear areas -- particularly the Psoas.

But what about my MRI? It clearly shows a tear and FAI. Well, according to him, that may have been what started all of this, but given the extent of the muscle tightness I've got and the fact that I've lived with this pain for roughly 1.5 years now, he thinks there's a good possibility that if it was a small enough tear it could have healed over or that, even if it didn't, it's not what is causing the pain.

It's not the first time I've been told about this possibility...isn't that the point of Dr. P's interest in trying to isolate the problem by using a shot of Kenalog (sp??). To see if it's the hip or if it's really something else that's causing the pain?  But I don't see him for another few months and in the meantime, I'm not sure what that means for me.

I'm definitely better on days that I do yoga, pool exercises, gyrotonic, or bike. Sitting or standing for long periods of time always triggers the pain. 40% of the time when I stand up, I still get that sharp shooting pain in my inner groin area in both hips. BUT, if I've been sitting for a while and try to stand up, that percentage is more like 95%.

I'm having a hard time mentally dealing with the hip limitations. There's a concert I really wanted to attend this week that I ended up passing on because it's standing-room only and I knew my hip would be screaming within 30 minutes. I haven't gone for a hike or a jog in so long. I miss it so much and I'm itching to give it a try.  But I'm pretty sure I shouldn't yet. This month has been particularly tough. Last year this month, I ran the Nike Women's Half Marathon and, despite fleeting and occasional pain, still felt on top of the world.  I'm having a hard time accepting that I'm not running at all anymore. Since that race, I think I've only logged about 4 miles -- all of which triggered excruciating pain. I was only a "runner" for a fleeting 9 months. How can I miss it so much?

On the other hand, I've come a long way from where I was a few months ago when I started this blog and had difficulty walking through a parking lot. I'm exercising about 5x/week, even if it's not particularly high cardio stuff...though I'm trying to build up my stamina.  I've lost weight and am still losing. I've learned a whole lot about the human body and the many muscles that stabilize our hip and help us move our legs. I've learned quite a bit about nutrition and have discovered some very different but complementary methods of cross-training. I've gotten slightly less neurotically focused on running and have gained a whole lot more respect for the body.

I want to throw my hands in the air and say, fine I surrender universe -- I accept it's not in my control. I'll keep doing what feels good and seems to make me healthier, but I will be grateful for all the blessings in my life and the fact that what I'm going through is hardly a big deal compared to so many people out there who are going through much more serious and upsetting problems. I really want to do that. But I'm having a hard time letting go. The irony though is that I'm not actually holding onto control. I never had any. So what am I holding onto so tightly?

Tempting Fate?

I have been very concerned with jinxing my progress by explaining how much better I'm doing, but I've decided to tempt fate and share it. 98% of my day I have no hip pain. That is HUGE!!!!! The other 2% of the time is when I stand up from a sitting position. And it doesn't happen all of the time. I'm still trying to figure out how to avoid the pain when I stand, because I assume it has something to do with the angle of my leg, hip, etc. But I feel like a completely different person than I felt when I started keeping this blog a couple of months ago.

Physical therapy is a gift from God. It has to be. I've been able to exercise pain-free, and I'm able to see just how strong I'm becoming. I have been increasing the intensity of the exercises (larger fins for resistance, increased number of squats, faster walking/running). And the water exercises have the added benefit of working my abs and arms also. That sense of accomplishment I got from running -- the pushing beyond my own mental and physical limits -- I'm getting that again, but in the water. And I'm even starting to enjoy the water. It's been hot here -- over 100 degrees each day this week. The water is a wonderful way to workout.

I'm still following Noell's 6-week eating plan (http://pickorstab.blogspot.com/) and I'm not really sure how many inches I've lost or how many pounds, but my clothes are getting very loose. I'm wearing a shirt today that I haven't worn in years (literally). Same with my pants. I even bought a new pencil skirt 3 weeks ago that was quite form-fitting, and I wore it yesterday and it was baggy in places. So, I assume that the reduced weight is helping relieve the pressure I'm putting on my hips also. 

I still haven't really resumed much activity beyond the pool-based, so that's my next challenge. Can I maintain this level of comfort and reincorporate some of the other activities I so dearly want to do -- bike, pilates, walk, yoga? I won't tempt the fates with running. I'm sad about that. There's a Keith Urban song, Till Summer Comes Around, and he's basically frozen in this place where he had a perfect summer love and hopes she'll return each year...she doesn't. He can't leave. I kind of feel like that's me and running. I fell in love, head-over-heals, and (due to my hip), running has said goodbye. I'm still wishing for it turn return to me, to give me the clarity of mind, the release of my over-busy head, the sense of accomplishment, etc. But I think I need to come to terms with the lost love and learn to love again. I'm seeing some shimmer of hope for a long-term relationship with the water.

I still don't know whether or not I'm going to end up requiring surgery. I know that the exercises I'm doing are not actually fixing my labral tear or FAI. They are just allowing me to function with minimal pain. I have a real concern that by not fixing the real underlying cause, I'm just postponing the inevitable, and when I do ultimately get the surgery, I'll have frayed more of my labrum, and caused much more damage to the joint. That is what is driving me to still meet with Dr. P and hopefully gain some more perspective. But at a minimum, I know that losing weight and strengthening my body is the best thing I can do pre-op anyway.

The rest is out of my hands. There isn't anything that this world can throw at me that I can't find a way to endure and of all of the possible things, this truly isn't that bad. Am I tempting fate? Maybe.

And a set-back

My enthusiasm may have been a bit too early....

This evening, I bent over to get something out of a bag that was on the floor, and when I went to stand upright again, I got the sudden sharp, excruciating pain in my hips. It was actually much worse in my "good" hip (the left one), but it was definitely present in both and I had to hold onto a chair for support. It went away within a few seconds.

This is the first of that degree of pain I've had now in about a week and a half. I'm so disappointed. But it may have been the angle that I was using, or maybe it was the fact that I stiffened when I was sitting for a while before that. Maybe it was the angle I was sitting on the couch. Maybe it was the fact that I worked out harder than I have in a few months. Maybe it's the fact that I have a torn labrum and FAI.

It's now been 2 weeks and I still haven't heard from the scheduler at Dr. Philippon's office. I fear that although the PT may help, I'll ultimately need the surgery and I certainly want to move ahead so I'm able to pursue that option. I guess I'll call the office tomorrow if I don't hear from them by mid-day.

Why can't things be easy and straight forward?

Too Good To Be True?

Ok, this is going to be a long post. This morning I met with another local orthopedic surgeon, Dr. Klapper, who is the Director of the Joint Replacement Division at Cedars-Sinai here in Los Angeles. I had an idea of what to expect from him because I read the book that he wrote entitled Heal Your Hips, in which he advocates non-surgical approaches to hip recovery and hip well-being. He only advocates surgery when the conservative approach fails. But what I like is that his conservative approach seems to be a joint pool and land therapy program. In his book, he discusses the downward cycle of hip pain, how it causes people to move less, and that lack of using the hip joint (and replacing the fluids in the hip) actually causes the hip to stiffen and results in more pain, when thus, makes you even less active, etc.

He looked at my films and the MRI and arthrogram reports, performed a physical examination of both of my hips to see at what point in the range of motion I have pain, and then he showed me on my x-ray where the extra bone portion is located and explained to me how that is bumping into the labrum. He said that it is FAI. BUT, unlike the other surgeons who have looked at my films, Dr. Klapper did not believe that I have mixed-FAI. He saw the evidence of it only on the ball, not the socket. If he's correct, and the portion of the socket were shaved down, there's no question it would make my hip unstable. So who is correct? YIKES! And ultimately, I'm not sure anyone can be 100% sure what's going on simply by looking at these films. I assume once I'm cut open, it's a whole other world and they'll actually see what is what.

But Dr. Klapper said words that I didn't dare to hope to hear:  "I don't advocate surgery for you, and definitely not yet."  Given the fact that this past week I've been nearly pain free and given that I have almost full range of motion, he suggested that I learn the pool therapy exercises and see if we can keep the pain from returning while slowly reintegrating activity into my life. He said that my labral tear was small and that although some surgeons will scare the crap out of me, tell me they need to cut sooner than later or I'll end up with early on-set of arthritis, they simply don't have the conclusive studies on that. Will I get arthritis? Maybe. But can I make some modifications to my lifestyle now to postpone it for many years? Possibly.

But Dr. Klapper said the words I dreaded -- that running is the best activity for mood, stress regulation and weight loss, etc., but the absolutely worst activity for your joints. He wants me to give it up completely. No running ever, unless I'm being chased.

At first, I immediately rejected that suggestion. And then I really thought about it. I'm not a professional athlete. Until last year, I wouldn't have even called myself an amateur athlete. A little over a year ago, I'd have never even considered running to be enjoyable. Now I adore it. Maybe I could feel that way about a different sport that is less taxing on my joints. I love to exercise outside. Okay. But I can swim, walk, and bike outside.  (Once I'm feeling better). I absolutely LOVE pilates. The mat work, at least, is not high impact. (Actually, I don't think it's impact at all, it's just the bending motion that was irritating my hip). If I want to do marathons or half-marathons, many of them allow you to walk. And I know first-hand, walking 26.2 miles or 13.1 miles is no easy task. What is it that I want long term? To be a fast runner? To complete Boston? Or to have a lifetime of mobility, activity and good health?

I keep hearing horror stories of complications from surgery. If you dislocate a joint, it's my understanding that that joint will always be a little less stable than it was before the dislocation. But that's what they'd do (to some extent) to get into the labrum to repair it. There are simply no guarantees with surgery, no matter who is doing the cutting.

Is it realistic for me truly to live a life with FAI and a small labral tear with minimal pain and moderate activity? Who knows. It certainly seems like I've got nothing to lose by trying. The pool therapy sounds like a really good idea to try because it's non-impact and I'll have someone trained to explain the exercises and watch me to make sure I've got the right form.

He wants to see if I've got any improvement in the next 6 weeks. Either way, I wasn't planning on having surgery then, so I don't see why I shouldn't give it a try. And if I ultimately need surgery, I'm still waiting around for a call from Vail to set a surgery date. And if I don't end up needing it, I don't end up needing it. Still, I don't want to get my hopes up. But if I could have a week like this week every week for the rest of my life (and I mean that level of comfort while doing activity, not while sitting around), I would definitely forego surgery.

But two conflicting ideas are swimming through my head, both trying to answer the question of why was this week so much better than the last bunch? 1) I did very little activity of any sort this week. That makes me concerned that once I kick up the activity level, I'll go right back to the pain. 2) I ate better this week than I have in months. No added sugar, no alcohol, no processed foods, regular healthy snacks and small healthy meals. Lots of water. I'm sure I've lost a few pounds. Maybe my excess weight is really a huge factor that the surgeons are awkward about calling my attention to. I know that FAI and the labral tear won't go away. BUT, maybe without the extra body weight, the pain would go away. There's only one way to know for sure, and it's about time I shed this fat!

Some News!

Ever have a problem that you can't wrap your head around, and that no matter how hard you think about it, you can't make any progress? You know that irony when you finally stop thinking about it, and suddenly the answer comes to you? That's pretty much how things seem to be working for me on this hip thing.  I finally accepted that I can't do anything to rush the process and I will just make the best of the time I've got during this waiting process, and I got a call from Dr. Philippon's office yesterday!

I can't remember the name of the guy I spoke to, mainly because I was so excited to hear from them at all that I don't think my brain was working at it's normal capacity. But he was nice, patient and explained a lot. He confirmed that my MRIs showed both a labral tear and mixed-FAI. 

But best of all, he asked me all sorts of really good questions that showed that he (or someone there) had read my incredibly long narrative of all of the information I thought that they should know about my medical health in general and the discovery and development of the hip pain. They asked me questions that showed that they were not just looking to jump in and fix the hip, but wanted to ensure that nothing else could be causing the pain, or that my other medications and/or complications from PCOS could be contributing factors. It showed me that they're looking at the body more as a system, than as a butcher might. It gave me some confidence.  It also gave me a little more confidence in my local surgeon's diagnosis.

 As I expected, however, it looks like the process is a slow one. And there are still no guarantees they'll ultimately operate on me. They asked me if I had gotten any injections (to isolate whether the pain is actually in the hip or if it's pain in the lower back that I feel in the butt, etc.). I haven't. I don't know if they'll want me to do that. They also indicated that, since they're backed up scheduling wise and are already into 2011, I'll need to have another MRI closer to the date of the appointment (whenever that'll be). That actually makes me feel better -- I don't want them to be surprised if they cut me open. 

But 2011 -- that's not particularly quick. And I won't even speak with the scheduling person to book a surgery date until approx 2 weeks from now (which I am just going to assume will be closer to a month). So I am guessing that realistically, they wouldn't be able to do the surgery before Feb/March next year.  The guy I spoke with explained that they're very busy -- they get 150 requests per month from people like me, asking for a review of films, etc., and Dr. Philippon does approx 40 of these surgeries per month. Seriously, I don't know how those numbers add up. Does the man sleep? Are there enough hours in a day? And I thought I had a busy schedule!

They're going to look into whether there's any local surgeons that they feel comfortable recommending to me in case things get worse quickly and I don't want to wait. And I still have an appointment with another local surgeon I found on my own. 

But in the meantime, I feel pretty good. Not much has changed between Monday and today, and, in some ways, my life has gained a new level of uncertainty. But I feel good. I don't know why. Peaceful. Like I've gained some acceptance finally. I trust that I'll take the time I need to take to make the right decision for me. And the result is beyond my control and even beyond the complete control of a surgeon. But if I give myself a half a year before surgery, I have the gift of time, which may ultimately be a blessing in disguise.

I'll have time to really research everything and be as knowledgeable as I can. That should help me go into surgery with confidence, which necessarily will help me recover. I'll have 6 months to lose weight. For sure that will help me recover faster. Think of all of that extra weight that I won't have to feel pounding down on my hip joint. I'll have 6 months to save money -- which it seems I'll need a lot of if insurance becomes problematic. I'll get to plan ahead work-wise, and not spring a long recovery on my bosses. And I get to be as mobile and healthy as I can be. 

Yes, I'm still in pain. A lot of it.  But I'm finding ways to live with the pain. No -- I really don't want to live like this permanently. I really want the surgery. But I think I can manage for 6 or so months. I went swimming today during lunch. It was only 20 minutes and I used a pull buoy so I didn't kick with my legs. But I really felt great and it's the first real cardio I've done in a while that I haven't finished in more pain than I started with.  Though my arms may be yelling at me tomorrow! I had purchased a waterproof ipod shuffle case/headphones from H2O Audio, and it worked like a charm. That made swimming laps a lot more fun for me. (I don't know why, but I just don't find swimming particularly fun). But it's exercise, and I'll take it! 

And who knows -- after swimming for 6 months, and biking during recovery and ultimately running again, maybe in a few years I'll end up doing something I thought I'd never be able to do -- a triathlon!

 I believe that we humans are given such amazing gifts, including the ability to choose how we perceive the world around us. We can choose to view a challenge as a roadblock or an opportunity. We have each other for compassion and support. We can focus on what we wish were different, or make the most of what we've got. 

So maybe the only real thing that changed in the past 72 hours is the way I've begun to view the situation. I truly don't have any more answers. But I have a measure of peace. 

I met with the surgeon...and my head is spinning.

I don't know why I was so nervous to meet with Dr. Guanche this morning, but I was uncharacteristically anxious. I arrived 10 minutes before my scheduled check-in time, and about a half hour later, I was given the necessary paperwork to fill out. Needless to say, the office was incredibly busy this morning. I was finally called back to meet with the doc, and offered whatever combination of MRIs/X-Rays/medical records they wanted. (I've got both the films and the electronic images). The assistant made copies of the reports of the MRI and Arthrogram, and uploaded the images from the discs. Meanwhile, I was given some disposable shorts to change into, and I had a very short wait. I realized that even though I had printed out a long list of questions to ask, I had inadvertently left that at home, so I quickly tried to reconstruct that list. Then doc came in and introduced himself.

To his credit, he asked me to explain the onset of the injury and where the pain is. (Always an annoying question to me, since I feel like an idiot when I say, "I really can't pinpoint the pain. It seems to move around, sometimes in the groin, sometimes in the front, sometimes in my butt, sometimes on the side...I just don't know.") He asked me about popping/clicking, and I said I didn't know if the sensation I experienced counted (I get what feels like when you crack your knuckles, but in my hip -- no associated pain with that though). He seemed to think my description was useful. I tried to recreate it, but of course, that was the one time my hip didn't crack.

I really appreciated that he performed his own full physical evaluation of my hip pain (i.e., range of motion test, etc.) instead of reviewing and relying on the notes from my referring orthopedists. That gave me some confidence. And apparently I'm pretty consistent -- the same positions caused that searing pain with prior exams were the ones that made me cringe this morning.

He showed me some images from my x-rays and MRIs (not sure if it was the regular MRI or the arthrogram), and explained that, not only do I have a labral tear, I also have a combined CAM and Pincer FAI.This was what I feared. It suddenly feels like a much more serious surgery -- removing a bit of my bone!!! I'm not sure why that scares me more than removing some of the cartilage, but it does. It feels so much more structural. And I'm a little concerned that this is the first I've heard of that. Neither my MRI nor Arthrogram Reports indicated the presence of FAI. To the contrary -- my lay man's reading of the reports made me think that there was no indication. (The arthrogram noted "There are no morphologic changes of the acetabulum or proximal femur to suggest primary CAM or pincertype femoroacetabular impingement.") So, I'm scared, I'm confused and I'm concerned. Why the discrepancy? Of course, I didn't remember what was in the report while I was meeting with Dr. Guanche, so I didn't ask him about it. He did show me on the images where he thought the FAI was.  But when I looked online at x-rays of normal hips compared to mine, I just don't know if I see it.

I did my usual skimming of google and came by a website with a roundtable discussion amongst orthopods about FAI and how they're being diagnosed more often, and how 86% of labral tears are associated with combined CAM and Pincer FAI. http://www.orthosupersite.com/view.aspx?rid=40509   That made me feel a little better, that this isn't coming from left field. And that my combination is not particularly rare.

Dr. Guanche took time to answer all of my questions, and I asked him everything I could remember to ask. I did remember to ask him about his feelings about the Game Ready ice machine and CPM machine that I've heard so much about. He said that over the past few months, he's been recommending devices like the Game Ready machine, but that he still has concerns with recommending the CPM machine, because it requires you use if for 8 hours (and most of his patients don't have that ability to do so given the need to return to work, etc.) and that he's concerned that if you slightly adjust your hips, it can actually rotate the hip slightly (and I suppose do more harm than help). The rest of what he told me sounded like what I expected. He told me that he performs approx 250 of these surgeries per year. (I forget when he started, 15 or 17 years ago?) He said that of those 250, annually, there are generally approx 2-3 that need revisions due to complications (scar tissue, etc) and unfortunately there's no way to know whether you're going to be one of the few upfront. I asked a lot about the physical therapy protocol, and I liked the fact that some of my PT would be in the pool. He said within 6 months, I should be able to resume my training, and when I mentioned my love of pilates, was very enthusiastic about my doing it pre-surgery and then (when ready) post-op. He said there were a few positions that would cause me discomfort for now, but most of it should be doable.

He was definitely not Mr. Gloom and Doom with the risks and side effects of surgery. I assume all of that is detailed in the reading materials he gave me, and probably in the pre-op appointment when I'm sure I will have to sign away my life in various legal documents. But truly, I expected a little more of the this-is-a-risky-procedure kind of speech.

After meeting with the doc, I met with the person who schedules surgeries and deals with insurance companies. She told me that most often, insurance companies deny this surgery because they consider it "experimental" or "investigative." They seek pre-authorization, and if it doesn't go through, you can of course appeal it, they will write a letter, but most often, it seems, patients pay out of pocket, and then after the surgery, mail to the insurance company the records from the procedure (showing it was not unnecessary) and sometimes the insurance company will then cover the procedure. But it's not cheap. I got a quote for the facility and doctor, but not the anesthesiologist or any of the physical therapy (which would be 3x/week for 12 weeks, and which I'm certain is not covered substantially by my plan), and I already had sticker shock. It certainly gives me pause. If and when I decide to do the surgery, they would start the process with my insurance company. But I didn't set a date because I am still waiting to get a second (and third) opinion.

I realistically can't do nothing. I'm in way too much discomfort for that. And I'm prevented from doing so much. And for the things that I can do, the pain still gets in the way. It's a constant. But I'm particularly concerned about what happens if this is in fact, CAM and Pincer FAI with the labral tear. I highly suspect I already have a small tear in my other hip, and if it's a bone structure thing -- that makes me think I'll probably end up down this road again at some point trying to fix that hip too.

So, the best I can do is to continue to get more information, continue to try to be healthy and to take each day at a time. I look forward to finding out if the other specialists also think I have FAI.