Sunday, 2 February 2014

Hip arthroscopy; the lead up, the procedure and the immediate aftermath

I have been influenced to write this by John Kynaston, who thanked me via facebook for my previous post. The intention is that;

1.      It will encourage others with similar hip related problems to pester their doctor incessantly until they are taken seriously,
2.      It provides a perspective on the operation and likely recovery process, and
3.      I provide a platform for fellow bloggers etc to answer a couple of (my own) questions which conclude the post.

The first section (the lead up) lists the events leading up to the operation. Several conclusions will be brought together to close this rather lengthy episode before proceeding onto the next; the procedure. Here I will go through the rather uncomplicated operation I had, before finishing this post with where I am now and what I think the future holds for me, as a runner.

The lead up

11 Nov 2012; I fell awkwardly coming downhill during a run. I didn’t actually land on the deck; I managed to keep myself upright but at the same time heard and felt a crack coming from somewhere inside my hips. From this day forth I had been unable to run or even powerwalk without severe pain materialising within my hips.

27 Nov 2012; I visited a sports injury clinic at Castle Douglas to find out what my injury was and to get some treatment – yes it took me 2 weeks to admit there was something wrong. I was given some Physiotherapy (PT) exercises and told to refrain from running for 2-3weeks.

21 Dec 2012; I waited longer than 3 weeks to give the injury every chance to clear before I embarked on a run on this day. The pain was actually worse - within the joint between my hip and the top of my right leg. I decided to stop running for as long as it took to clear the injury and assumed on the basis of previous advice that this would be no more than another week or two. I continued with the PT exercises suggested – again almost refusing to believe I was really injured.

10 Jan 2013 (2months post injury); I phoned my GP,  because the hip injury was not clearing despite very low levels of activity and to enquire about being put forward for a referral. When he informed me that the process could take as many as 18 weeks I agreed that it might be of use if I simply re-visited the sports injury clinic. This is the date I first enquired about a referral.

12 Jan 2013; I was unable to get an appointment at Castle Douglas for a couple of weeks but I did manage to get in at FASIC in Edinburgh that Saturday morning. I was given a thorough examination and thereafter, a number of PT exercises and told to refrain from running for another week or two. The specialist did not seem concerned about the pain I described which was referring into my groin.

16 Jan 2013; I had been emailing the physiotherapist at Castle Douglas to update on my progress and was invited to attend again on this day. He ran some checks and confirmed the diagnosis made in FASIC; femoral anterior glide syndrome with medial rotation. He concluded by giving me a variation of some of the PT exercises I had already been doing for nearly 7 weeks. He also said I could continue with my running and that it should be done up to the point of pain and when the pain kicked in I was to stop and carry out my PT exercises. He added that the injury should clear up soon and the clicking noise within my hip would soon dissipate. He did not appear overly concerned about the pain that I described which was referring into my groin.

22 Jan 2013; I wrote to my GP to explain the events above and to request that I be put forward for a referral with a specialist. I did this because despite being told by a number of specialists that my injury would soon clear up (since the end of November) it had shown no signs of abating. I wanted to start the ball rolling with the referral process then rather than wait months for someone to acknowledge that it wasn’t clearing and then begin the lengthy process.

23 Jan 2013; sub note to add that both by regular osteopath and physio disagreed with the diagnosis of the specialists thus far.

27 Jan 2013; I went for a 4 mile powerwalk to investigate the condition of my injury. This was my first attempt at rigorous forward movement since my visit with the PT at Castle Douglas (2 weeks earlier). Within 10minutes the pain re-emerged within my groin and gradually got worse for the duration of the walk. Afterwards I decided to pull out of the entire years competitive commitments on the basis that I would not be physically ready for any of them. THIS WAS WHEN I STOPPED RUNNING.

01 Feb 2013; my GP replied via letter and made reference to the issue that I wanted to return to running as soon as possible but requested that I be patient with the process of rehabilitation, therefore turning down my request for an MRI. I took up Yoga this week.

20 Feb 2013; (more than 3months since the injury) I visited the physio in Lockerbie and was with her for almost 90mins. I explained the following;

·         My pelvis appears to be pulled backwards during the night when I’m sleeping.
·         When I wake in the morning I am aware of an isolated area of acute pain in one spot of my lower right back.
·         The two large muscles either side of my spine feel fatigued most evenings.
·         I often roll backwards and forwards on my back (with my knees tucked in to my chest) to get rid of the perceived build up of fatigue.
·         I experience a very strange creaking sensation within my upper right groin whenever I do a backwards lunge; almost like the stretching of a rubber glove.
·         The clicking noise in my upper right groin shows no signs of abating.
·         I’m in constant daily pain and this is despite being almost completely immobile lately.

She was very thorough and explained that the core has four parts to it and all need to be working in unison to help prevent injuries. She also corrected a slight imbalance in my lower back. I’ve been told to continue with the PT exercises and also try to engage the entire core and to focus on doing the exercises properly i.e. keeping the pelvis aligned properly. There was no time limit given for when I should expect to resume full fitness from injury though she did say that it could take as much as 12-18months!

19 Mar 2013; there were still no changes in any of my pain symptoms. I was concerned that almost 4 months of conservative treatment had not helped in any way. Therefore, I wrote to my GP again.

22 Mar 2013; my GP replied to inform me that he had forwarded my letter to the MRI dept at DGRI for further assessment. This is the date my referral process eventually begun.

15 Apr 2013; my wife (works in Radiography etc dept) told me that Dr Haque had spoken with her re my condition. He says that he would prefer that I get properly diagnosed. That way I will either have an arthrogram or a plain MR. Apparently, my GP should have referred me to a specialist in the first instance.

18 Apr 2013; I have a Hemorroidectomy (operation) and am fairly immobile from this point onwards for a number of weeks. I volunteered for this on the basis of having to cancel my running commitments this year.

19 May 2013; I’m recording this date to demonstrate the ongoing nature of this problem. Whilst walking the dog this morning I felt a number of sharp twinge’s within my upper right groin i.e. the same area that I have been having pain in for the last 6 months. This is despite the fact that I stopped running in January and have been practically immobile the last 5 weeks due to having had a Hemorroidectomy.

03 Jun 2013; first activity since my Hemorroidectomy operation – a 4 mile walk. I had a niggling pain in my lower right back and across my right side trochanter. I’m still getting the popping/snapping sensation coming from my right hip at the front.

04 Jun 2013; my right greater trochanter felt as though it wanted to pop out this morning whilst walking the dog – the day after my 4 mile walk.

07 June 2013; 30wks since injury, 11 weeks since official referral, I have received an appointment for the orthopaedic specialist – 11th June.

11 June 2013; appointment with orthopaedic specialist. He says that I have a bony prominence on my right hip ball joint and that this may be causing a labral tear which is referring into the area at the front of the hip. He says that the greater trochanter pain may be simply due to a bursa which is not pertinent at the moment due to my level of inactivity. He also added that the psoas may be degenerated and that the scan may or may not confirm this. Either way, if it is, there is no repair that can be done. I am to have an arthrogram MR at Glasgow Nuffield soon. I hope to find out what condition my psoas is in so that I can make a decision one way or the other.

16 July 2013; 35wks since injury, almost 17 weeks since referral, I returned to find out the results of my scan. The specialist confirmed that I have a labral tear and that he is going to refer me to Glasgow General for the next stage of my treatment. My appt was 0900hrs and I was not seen until 0940hrs; just to be told this very quickly. Why could I not have been consulted with over the phone? This would have saved my time (I took the morning off work) and the time of time of the consultant.

29 July 2013; constant hip pain. The pain is now referring deep into my ball and socket joint and is a constant burning sensation. At least the pain into my groin has dissipated. I’m wondering if my ongoing ITB strain can be addressed at the same time as any potential operation to my hip?

01 Aug 2013; I phoned Glasgow today (Mr Patel’s secretary – the consultant that was supposed to see me) to be told that I had to wait up to 12 weeks if I was to be seen and that she couldn’t even confirm if I would be seen at all as it would be up to the consultant. Almost 9 months since my injury and I’m being told I need to wait another three just for another consultant meeting.

30 Aug 2013; 41 ½ wks since injury, 23 weeks since referral, I phoned to ask what the progress was only to be informed that Mr Patel (above) had declined my referral requesting that Dumfries stop sending him referrals because he is too busy! I’ve now, as of the 23rd, been re-referred to a different specialist in Glasgow; Mr Campton at the Gartnaval. I phoned the Gartnaval to be told they had no record of my referral and that when they received it I would be looking at 12 weeks to be seen again unless it was marked as urgent. I phoned Dumfries and asked them to fax the referral through today and mark it as urgent.

23 Sept 2013; 44 ½ wks since injury, 26wks since referral, I phoned the Gartnaval to find out when my appt is due. I was told that my referral was marked as ‘routine’ and that I would not be seen until November at the earliest; a year since my injury.

26 Sept 2013; I write a complaint to the NHS

12 Oct 2013; I visit a play area called ‘crocky trail’ with my kids and run about playing with them. The day after and for another couple of days the top of my right leg and down into my groin is in incredible pain i.e. I definitely cannot run anymore.

11 Nov 2013; a year to the day since I was injured, 34wks since referral, I have my consultation with Mr Campton. He says he will help me.

30 Jan 2014; 14 ½ months since injury, 10months since referral, I have my operation and it turns out that I was more in need of this than had been previously thought!

So what can be taken from this period of time?

Up until my Xray (which was 7 months to the day after my injury) I had four separate professionals all telling me that I had the same injury; each of these individuals had no means of collaborating with one another and none of them was informed of any previous diagnosis.

Under normal circumstances a person would have been considered deluded to question four individuals each with considerably more medical knowledge than his own. However and with this clearly in my thoughts, I remained totally convinced that they were wrong. Here’s why;

1.      When you are injured and unable to train at your chosen sport for any more than 5 weeks then you have a real problem that needs addressed. This simply doesn’t equate to 12-18months of physiotherapy as one of the individuals suggested,
2.      I had pain referring into my groin which was consistently overlooked by every professional,
3.      My osteopath and personal physio both told me that the diagnosis’ of my injury didn’t make any sense to them,
4.      Some people have a higher tolerance to pain than others; I suggest highly driven individuals such as ultra runners fit within this bracket. Therefore, to be fair to the four who got this injury wrong, diagnosing can be complicated by this factor,  
5.      Two of the physios suggested that I should be able to run after just a few weeks of the PT exercises but had no suggestions for when that proved incorrect, and,
6.      Quite simply, I didn’t believe anyone was taking me seriously and got the general impression that I was being fobbed off.

These tactics may deter less determined individuals from pursuing further action through the NHS and this is where I believe the crux of this matter lies. Please, someone/ anyone correct me if I’m wrong because this entire affair has blighted my view of the NHS. In fact, if it was up to me I would like to opt out of paying my NHS contributions with the aim of taking out health insurance instead.

I know they are chronically under resourced but they should not be making promises such as ’18 weeks from referral to procedure’ when they clearly can’t keep to them.

The procedure

At my pre-operative assessment, I was told that I was going to have a hip arthroscopy with the potential for a labral repair and/ or osteoplasty (bone shaving). I was also informed that I would be in crutches for between 4-6weeks, and that the more I had done, the longer I would be in rehab for afterwards. The time to resume full activities was placed at roughly 6 months.

During my own research, prior to the operation, I uncovered some wild stories of people being in severe pain post operation for anything up to 18months! I admit that I was very anxious especially given the complications I suffered from my haemorrhoidectomy last year where I could barely walk for 8 weeks afterwards and have been left with a prescription of laxatives for the rest of my life.

However, for me this operation was a final throw of the dice; without it I would never run again. I might never run again with it but at least there was a chance that I would. And despite the potential for monumental pain in the aftermath I considered it a chance worth taking.

Hip arthroscopy is a procedure that allows surgeons to treat many hip problems that previously required large incisions, muscle splits, and dislocating the hip. The surgery generally takes about 2 hours, and is performed through two or three small incisions in the upper part of the thigh/groin. A small telescope (the arthroscope) is placed into one of these incisions and the entire hip joint can be visualized. The arthroscope is connected to a tiny camera, allowing the entire surgery to be visualized on a TV monitor. The other incision(s) are used to place various instruments into the hip to perform the surgery. A special operating room table is used to perform hip arthroscopy to gently distract the joint and allow for safe movement of instruments inside the hip.

 
Now, it was the consultants’ intention to repair a labral tear. However, it turns out that my tear was larger than expected, so much so that it was beyond repair. Instead (I was informed afterwards) he removed much of the debris and smoothed out the labral joint.

In addition, he had to reshape the neck of my femur as a bone deformity was causing an impingement (femoroacetabular impingement to be exact). It was this that caused the labral tear and regardless of whether or not I had taken a tumble on that fateful day, at some point in time this was always going to happen.   

 
During my research I have come to realise that many people have labral tears to some degree and that many of them do not require surgery. I think it’s important to state this as these things should be taken on an individual basis. The same goes for the recovery process.

 
The immediate aftermath

So I had the operation exactly 3 days ago from now. Within hours of the procedure I was up walking to the toilet without the aid of crutches and have to say that I was pleased to feel only minor pain.

The consultant visited me the following morning to tell me what he did and answered the first question on my lips; did he find any signs of arthritis? The answer was that yes, yes he did.

So here it is folks, what do I do now?

I told the surgeon that I had my sights set on one last hurrah before putting the running shoes away for good and asked his opinion. He was non committal as I suppose any true professional would be.

He said that I should be able to resume a normal level of activity but that I would always experience some minor niggles within the hip region. Thankfully though, none to the extent I had felt within the last 14 months. Instead, he said I would probably not notice it too much but just to be aware that things would never be perfect.

At 37yrs old I now know that the head of my femur is ‘scruffy’ i.e. that I have the onset of mild arthritis. Being realistic, and assuming I live to about 80, this means that I can expect a hip replacement at some point in my life.

So the burning question is this, can I resume running once I have rehabilitated from this operation or should I just give up once and for all?

Truthfully? I have already prepared a training programme based on me arriving at the start of the 2015 fling. This has been based on the principles of injury prevention and running/ training the absolute minimum that is required.

I aim to reduce my bodyfat significantly prior to starting running base training; over the last 4 months I have went from 13.4% to 18.3% due to strength training with the aim of bulking my upper half up – to bring some balance to my overdeveloped lower half. The problem is, I made a huge balls up with my nutrition – despite witnessing some lifetime best strength gains.

 
Thereafter, I have 3 block of 12 weeks running training each with a two week active recovery period between. All of this has been specifically tailored to match my own abilities and is based on everything I have learnt within the last 5 years.

My only concern is that I may have missed something. For example, I know that I keep getting niggles on my right side. Therefore, does anyone know of a specialist I can visit who can assess me and help me with my running gait or alternatively, even tell me straight that running is not good for me?

Until then, I really hope I at least get the chance to fulfil my dream.

 

 

 

 

 


 

 

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