Where to next? (Medical practitioner question)

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CKinnard
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Re: Where to next? (Medical practitioner question)

Postby CKinnard » Fri Sep 28, 2018 10:32 am

Key points:
- pain inhibits muscles.
- chronic pain inhibits, and reduces muscle size.
- chronic pathology, even without pain, inhibits muscles (due to the 'kindling' effect on neuro circuits)

Considering the pain you have had, you are going to be weak with back extension.
Core muscles are not the only thing that get inhibited, everything gets weak....and this is my beef with the Uni of Qld founders of core strength rehab. They are smart guys (Paul Hodges) but were very passive in countering the hysteria and unbalanced therapeutic approach around core stability.

And it is not just the core that helps stabilize the back posturally and with common movements.

Further, how well you respond to these exercises ultimately depends on the underlying pathology.
Too often I see physios do their thing without a clear understanding of the underlying cause of pain.
If there has been a long hx of inflammation and resultant adhesions; or arthritic degeneration of facet jts; or calcification of facet capsules, dura, or ligamentum flavum; or anything that contributes to progression of a spondylolisthesis, then getting results requires a multi-disciplinary approach as I have mentioned before....because exercise alone is not going to address the tissue that is sending pain signals to the brain.

vosadrian
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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Fri Sep 28, 2018 1:34 pm

Thanks Ckinnard....

Not sure if I am reading right, but I think you are saying that it may not be possible to get the result I am after since the pathology cannot be treated without surgery... so Physio may provide some benefits but may have limited improvement?

For me, with the professionals I have access to, I am going to have to see more debilitating issues on the scans before any surgery is going to happen. It would be remiss of me to not try every conservative approach I can before surgery anyway. I may be satisfied with what I achieve conservatively... or if I am not I will at-least know I gave it the best shot before surgery, as there is significant risk that surgery may not achieve an optimal result and I would not want to go down that path and possibly regret the decision later.

Anyway given the conservative approach I am taking at the moment, It sounds like I am heading in the right direction? I wish I could self treat with advice from experienced people like yourself, but I have tried that and failed. I think I struggle with correct technique in doing exercises, but I do not know how to improve the technique. I think I need some help to get going on the right path at least initially.
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CKinnard
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Re: Where to next? (Medical practitioner question)

Postby CKinnard » Fri Sep 28, 2018 3:37 pm

The pointS I am making are
- core stability training is not the be and end all.
- neither is building non core strength
Nevertheless, I suggest you improve strength in both.

- pain relief depends on settling whatever is driving pain signaling from your back.
(I don't buy into your pain being driven primarily from higher centers. Some physios try and sell this spiel).
Your pain may have components of adhesions, space occupying lesions, cysts, abscesses, calcified mechanosensitive dural or meningeal linings, capsulitis, facet jt cartilage degeneration, osteophyte irritation, and hyperalgesic and/or hypoxic disc annular and nucleus regions.

My shot gun approach would be to do all possible to address all of the above, which would involve simultaneous multivariant exercise, posture, optimized nutrition, extended fasting....and I appreciate we have talked about your views on each of these before.
Needless to say, you have a chronic persistent condition that is ripe for experimenting with various conservative therapeutic interventions.

vosadrian
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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Wed Oct 24, 2018 3:02 pm

Hi All,

Just an update and a question to those who know more about the human body than I do.

First on updating. I am almost 4 weeks with my new PT. He does some joint mobilisation of back and hips and stretching which mainly focuses on the hamstrings which are ridiculously tight for me (and do not seem to get better despite my constant stretching of them). Then it is into the Gym where I use the MedX lumbar machine and a bunch of others for strengthening muscles of core and hips. The main machine is the back machine. When I started I was struggling to do 95 (ft.lb??) for about 2 minutes (25ish reps). I have worked my way up to 125 so far with a target of around 160. So whatever muscles I am using to do this exercise (hopefully deep extensors) are getting stronger. Also, I am increasing the weights on the other machines I use (hip extension, Torso rotation, Hip ABD/ADD, Oblique etc.). So in general, I believe I am strengthening areas of my core and hip muscles. But I am not experiencing benefits in pain.... yet. I live in hope. It will take me a couple more month to get to target strength levels. I started very weak (well below bottom 15% percentile for my demographic).

Now onto my question. My symptoms are documented in this thread. The main part of my symptoms have been lower back pain (RHS focused) with pain wrapping around side, inguinal area into groin and upper thigh. I came across this thread on a cyclist forum which sounds a fair bit like the situation I am in (but I have radiating symptoms on top of this):

https://www.velocipedesalon.com/forum/f ... 20681.html

Basically a fairly high level cyclist with "chronic SI/ low back pain/hip pain" who had been on a similar (lack of) diagnosis path to myself and eventually saw a hip surgeon who diagnosed FAI (hip impingment). Surgery fixed him and he is all good now.

Got me wondering about myself, so checked through some of my previous radiography and found a few report items that have never been really investigated as the scans were looking for other things. I am wondering if they could indicate I may have a similar issue:

In a sacral spine MRI from Nov 17 (This does not say which side):
Hip Joints and Surrounding Musculature: There is focal bone marrow oedema deep to the anterolateral acetabulum. There appears to be an underlying non-displaced labral tear. There is no joint effusion.

In a left hip MRI from Oct 17:
Both femoral heads are well located within the acetabula, the joint spaces are preserved. The chondral surfaces are well maintained. The acetabular labrum on the left side is focally torn at the 12-o'clock position, with a small paralabral cyst, I suspect this is incidental, without adjacent marrow oedema. The right sided labrum has a normal appearance. There is no joint effusion or synovitis. There is no marrow oedema.

In a groin MRI from June 16:
Hip Joints and Surrounding Musculature: Relative reduction in lateral femoral head/neck offset noted bilaterally. The surrounding musculature generally outlines normally. There does appear to be any significant effusion. There is a suggestion of some minor fraying of the labrum anteriorly bilaterally. There is a small anterior tear on the right. There does not appear to be any significant articular cartilage loss and the ligamentum teres remains intact.

In a hip MRI from May 16:
Findings: There is mild loss of femoral head/neck offset at the antero-superior margin of the right hip, without a dysplastic bump. There is a trace of underlying bone marrow oedema. In the appropriate context, this may predispose to cam-type impingement. Femoral head coverage is normal and the acetabulum is not retroverted. There is minor high-signal in the anterosuperior labrum, consistent with minor intrasubstance degeneration. No discrete tear or paralabral cyst is identified. The labrocapsular sulcus is not effaced. Articular cartilage is preserved throughout the hip. There is no evidence of established osteoarthritis. No evidence of insufficiency fracture or avascular necrosis. Wide field of view imaging demonstrates a probable tear of the left superior labrum.
COMMENT: No displaced right labral tear. Articular cartilage of the right hip is preserved.

Soooooooo...... I have been down so many diagnostic paths that have cost me much time and money and further pain and suffering. My question is whether my some of my symptoms could be caused by hip impingement and whether I should try to follow this up further.... or are these finding incidental and normal healthy (asymptomatic) people have similar findings.

Cheers,

Adrian
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CKinnard
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Re: Where to next? (Medical practitioner question)

Postby CKinnard » Wed Oct 24, 2018 4:20 pm

Your pain presentation doesn't fit primarily a referred pain from either hip, or adjacent pelvic bone.
And hip pain doesn't cause numbness in/under the feet.
And from memory, you have rested your hip joint for a long period, which should have calmed pain from hip pathology significantly.
Hip pain is also likely to be worse with increased hip joint use.

Nevertheless, get your physio to assess both hips with provocation tests, etc.

edit:
just read that url about the hip surgery. Steadman-Hawkins would be one of the top 3 orthopedic clinics in the USA (and world).
Richard Steadman is a world leader in lower limb sports orthopedics, especially knees.
Richard Hawkins is upper limb, esp baseball pitcher shoulders.
Both these guys would be recently retired afaik but have founded excellent research facilities and teams of surgeons.

The cyclist who had the hip issue who said no physio suggested his hips must have seen some pedestrian US physios.
Generally, their training is inferior, and their practice is hobbled having to follow health insurer protocols.
My training was to always clear hips and knees with chronic low back pain of unusual presentation.
But 'clearing' adjacent joints can be inadequate due to a patient's low pain thresholds.

vosadrian
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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Thu Oct 25, 2018 11:48 am

So my RHS sciatic nerve symptoms don't fit with a normal hip joint thing. I can say though that the guaranteed way to trigger them is hip based. Basically putting my hip in certain positions will trigger the numbness down the legs. This is really the only trigger. I can put my back in any position I can thing of and cannot trigger the numbness. I used to lay on my left side on the lounge in the evening to watch TV (bending sideways at hip to get my head level with hips slightly flexed and knees flexed at about 90deg), but I can no longer do this. I used to sit in a chair with my right leg crossed with right foot on left knee (and shin near horizontal), but I can no longer do that. Both these actions are limited by hip ROM and both will cause my RHS foot and parts of back of leg to go numb and it can take days to weeks to return "normal".

As to Physios.... well they mostly check my hips for ROM. The most common test they do is the one with me lying on my back with thighs vertical (hips 90deg flexes) and shins horizontal (90 deg flexed at knees). The then hold my knee in position and rotated the foot outwards and inwards to check range of mition (ROM). Typically on this this test, my LHS is poor external rotation and my RHS is pretty good.

The second test is in same starting position (or perhaps with feet on bench with hips less flexed and knees at 90deg), and rotate my knees outwards (so moving thigh towards horizontal). With this one my LHS is good (can go flat without pain), but RHS is very tight. I get maybe 2/3 down (30deg off horizontal) before ROM is limited by something which seems to be in my inner upper thigh/groin which gets tight and painful.

The physios always explain above as imbalances and I need stretching and strengthening to correct these imbalances. They have never mentioned if this could be a joint range of motion issue and I don't know if it could be. There solution is mobilise the joint by pushing it against the ROM limits and to strengthen glutes and Hip ADD/ABD. The current Physio is doing this, and I I have to say that the groin pain is getting worse... probably from this.

My observation of working with a bunch of physios is that they very rarely suggest a mechanical issuse that cannot be solved with PT. THey normally think it is tight/weak muscles and seem to rehab that. I have not one ever suggest that I need surgery to my back or my hip. One did jump on the sciatic tumour as the cause of my issues and wanted me to get that fixed surgically.

In terms of aggravation of symptoms. They do not ease significantly with rest, but they do ease to a baseline. Sitting in a desk chair aggravates it also. I am happiest walking or lying down, but I prefer to stand at a standing desk than to sit. Riding has a two fold effect. When riding, I generally feel OK in hips as they loosen up with movement but back gets sore and glutes tighten up on a long ride. As the body cools down, then tightness around hip settles in. You ahve seen my other thread whertre I was trying to adjust bike fit to reduce hip flexion.

This is more detail on some aspect of my symptoms and the Physio treatements. I am not sure if any of that can point towards hip impingement or not.

Thanks for you input!

Cheers!
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CKinnard
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Re: Where to next? (Medical practitioner question)

Postby CKinnard » Thu Oct 25, 2018 12:05 pm

Below is a video of a Steadman Hawkins surgeon talking about FAI, though this is a few years old now.

Physios who say that exercise and increased joint range can fix pretty much everything give the profession a bad name.
It's as bad as chiropractors saying cracking joints is a universal panacea.
The first and foremost priority is to get the diagnosis right.

https://youtu.be/1l_lWTIf_JM

Mark Hutchinson has a good rep as well, and goes through ax for labral tears below.
My ax is more provocative, as I've seen too many labral tears missed via too conservative ax.

https://youtu.be/Rtp4oz0_3YY

FAI and labral tears tend to go hand in hand.
FAI can develop in response to repetitive stress, which causes either the femoral head or the acetabular ring to lay down more bone, similar to an arthritic knee joint. The additional bone starts to compromise the labrum and joint range of motion.
These arthritic pathologies are very much tied to diet and systemic inflammation, but you say your diet has been optimal for reducing inflammation.
Last edited by CKinnard on Thu Oct 25, 2018 1:15 pm, edited 2 times in total.

RhapsodyX
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Re: Where to next? (Medical practitioner question)

Postby RhapsodyX » Thu Oct 25, 2018 1:13 pm

Re. the PT doing "joint mobilisation" - mine has been BANNED from touching the lower spine. Every time he decides to "improve" joint mobility, I have symptoms for a week. Ditto for rotation - that irritates the hell out of the nerves and causes numbness and tingling that takes days to settle down. There are things I *cannot* do without making my symptoms worse - so I don't do them. But I'm now riding ~ 300km/week, I'm back at about 90% of where I was. And by concentrating my efforts on core stability, I have less episodes of "That hurt". The fixation of "range of motion" and "flexibility" is (according to McGill) closely-coupled to the rehabilitation industry needing to have some measurable criteria, NOT because it improves long-term outcomes.

BTW - I found out the other week that there is such a thing as a "high resolution MRI". The recipient was being written off as having incurable neuralgia in his face, but it was timed to his pulse rate. He got a referral to a specialist in Sydney who sent him for a hi-res MRI, which found a blood vessel in the back of his brain which had rubbed the myelin off a nerve bundle. Cue brain surgery... cured.

vosadrian
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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Thu Oct 25, 2018 4:50 pm

I never said that my diet is optimal... but I suspect it is better than most from an Aussie diet type perspective. I eat a wide range of food types mostly home made and mostly with fresh quality ingredients. Not much deep fried foods except once a week for lunch. I suspect I have lowish fat body %. Typical breakfast is muesli with dried fruit and yogurt. Lunch either a healthy (quinoa) salad or ham/salad roll (subway) or dinner leftovers. Dinner is often meat and 3 veg or pasta or stir fry. I am no whippet climber... more a smaller sprinter type but fairly lean. I have been through times where I have tried to eat an anti inflammatory diet for periods of up to about 8 weeks (tumeric in foods, low sugar, GF, particular rices etc.), but have not noticed any benefit.

Thanks for the videos. I should note that no physio has ever done any type of test as the video. After watching the second one I was reminded of a symptom I have which I don't know if it is relevant. Getting out of my rather low car (drivers seat). I used to slide my right leg out to the side and then use my right leg to get up out of the car (like a normal person!!). I noticed a few years ago that I was getting an audible click which was also painful (not bad... more tender, but something I preferred to avoid). At the time I noticed it was becoming the new normal, I did some google and came to the conclusion that it was snapping hip syndrome which seems to be a tendon sliding over something which did not seem to be too serious so I left it at that and adjusted my technique of getting out of the car. These days I shuffle my body around to keep legs together and facing out the door and get up with both legs. I am not sure if that is a positive test similar to the second video.

Another thing to mention. Getting on/off my bike. I used to have lots of hip flexibility and would just walk up to my bike in a normal vertical oriented position and lift my leg over the seat/frame to get on. In the last year or two, this has become difficult. It seems to be a combination of reduced ROM and weakness, but I have trouble lifting my leg high enough to get my leg over the seat. So now I have to lean the bike over towards me to lower the saddle height and then swing my leg over. I habitually swing my right leg over to get onto it, but it has never occurred to me to try the left leg and see if it is better. I will try that. Not sure if that is a ROM indicator.

And one final thing to mention. About 18 months ago another rider who has had pelvic issues was riding with me and noted that my right knee was kicking in close to the top tube at the top of my stroke. I'm pretty sure this was a new development, as I had never noticed it before and I had noticed it previous on left side when I was fatigued some time ago. Coupled with that, I started noticing that when I got fatigued on longer rides, I seemed to struggle to pull the right pedal forward over the top of the stroke. What I noticed was that I was clicking the rear hub ratchet as I took torque off the cranks when I dragged it over the top and then reapplied torque as the quads engaged to push down. This was a new thing after years of cycling. My LHS was fine. I actively tried to fix this by foam rolling the abductors and strengthening the abductors and trying to ride pushing my knee out. This was partially successful, but if I am not concentrating I do the same thing again. This typically happens when I do a longer ride than normal for me. As I get more fitness it is less, but if I do not think about it, the knee kicking in thing returns.

Thanks RX. I am leaning in the same direction. The Physio had convinced me of the stretch and strengthen thing so I have been letting him do this. If he is right.... I guess I am doing the right thing, but if there is some change I have hip impingement, I imagine what he is doing could aggravate the condition and have no benefit in fixing it.

I have gone to my doctor so many times to ask for a referral for some new specialist that he is sick of me. Should I do the same again for a hip surgeon/specialist? Do I have enough suspicion that this could be a possibility to go see a specialist. It seems I have not been able to find a physio that can check it properly (well they have not included it as part of their check), and I need an expert opinion to rule it in or out. If I am reading this correct, there is not a conservative fix for hip impingement? Basically this is a case of mechanical interference of the bones. Rehab cannot correct it. So conservative treatment is avoid the impingement and strengthen the muscles to control the motion better, but ultimately if you push the joint to impingement again, it will get re aggravated?

As to how a hip issue could fit into the general picture of my symptoms.... well I have a theory, but I am an engineer... not a health professional. I suspect if my hip joint had an issue, my nervous system would respond to protect it by tightening up the muscles around it. This is something I definitely have. Many muscles around pelvis are tight and over active. Every Physio sees this and tries to treat them. This would limit ROM of the hip and would force the spine to flex more to make up for lack of flexibility in the hips and could cause muscle issues around the spine and general back pain. I have this. As for the numbness.... well there is not much of that LHS since the tumour was removed. so mainly RHS. Could be two possibilities I see. The sciatic nerve passes through the muscles around the hip (like piriformis which is tight and hard and tender). Given I have nerve symptoms with external rotation of the hip, perhaps my sciatic nerve is getting compressed by tight muscles like piriformis and causing numbness? Other option is that it is in the spine which is working more due to hip inflexibility. I think this all could explain my very posterior fascia chain. Hamstrings have gotten tight trying to protect hips/back.

What a long post.... sorry about that.
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CKinnard
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Re: Where to next? (Medical practitioner question)

Postby CKinnard » Thu Oct 25, 2018 5:59 pm

Most hip movements will traction your lumbar and/or sacral nerve roots.

Without assessing you personally, it is difficult to differentiate hip and lumbar spine originating pain.

Based on the difference in ROM of your hip joints, it is likely you have (R) hip pathology, though it might just be capsular thickening and shortening.
Your symptoms might also be due to hip nerve supply irritation.
- the obturator nerve supplies anteromedial hip jt
- femoral n. the anterior hip jt
- sciatic n. the posterior hip jt
The first two nerves originate from nerve roots L2,3,4).
The sciatic from L4 to S3.

One intervention that might clarify are sequential peripheral diagnostic nerve blocks of these.
Or even a celestone shot into the whole hip joint would be telling.
However, good luck finding a specialist who does diagnostic blocks in this region.

Nevertheless, you still have sciatic symptoms in both feet, which takes you back to bilateral lumbosacral pathology....and I don't think any of the specialists you have relayed your encounters with, has adequately discounted its involvement.

Another approach you could take eventually, is to focus for 4 weeks on exercise and flexibility for the hip joint/muscles specifically, while not challenging the lumbar spine.....then vice versa. And seeing which stirs your symptoms most.

vosadrian
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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Fri Oct 26, 2018 8:58 am

When I consider the order of events in my symptoms, the sciatic symptoms in feet came well after the back/hip issues. The order was LHS ankle closely followed by RHS ankle. Then when doing lots of swimming and no cycling about 6 months later, it was RHS lower back right out the side on the pelvic bone (further lateral to SIJ) that then quickly (weeks) wrapped around side down inguinal canal and into groin and upper thigh. Then I had tightness and pain in LHS glutes and then RHS. Then Sacral numbness some time later. Then I had numbness/pain in RHS foot and then LHS. Surgery to LHS sciatic nerve has mostly (still post surgical pain) alleviated LHS glute issues. More recently I have developed more central lower back pain. This central back pain has been ongoing for many years but was mostly something that was not constant and it has become constant. There were symptoms that were ongoing but no big deal and they would come and go. For instance I had groin pain before this all started, but it was minor and would come and go. I had foot numbness that would occasionally come before this all started. I would tweak my back ever 6 months or so and take a weeks or so to recover. There was nothing chronic before the ankle.

So my thoughts are the symptoms that developed earlier are likely to contribute to later developing symptoms, and the hip pain was much earlier than the sciatic symptoms. Has adaption due to inhibition from the earlier symptoms caused the later?

Anyway, it sounds like I should get the hip assessed properly. Anyone know anyone who can do this in Sydney? Preferably someone who can order tests to confirm the diagnosis, so probably a hip specialist doctor/surgeon. The testing suggested by CK sounds optimal, but no doctor I know will order those nerve blocks. I think I just need someone who is good with following the normal path of diagnosis for hip issues. A quick google says all the good hip surgeons are in Melbourne but surely there is someone in Sydney who is good for the diagnosis phase?
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CKinnard
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Re: Where to next? (Medical practitioner question)

Postby CKinnard » Fri Oct 26, 2018 11:50 am

You might get a radiologist prepared to do a celestone injection into the hip joint.
That would be very insightful, and similar in clarifying to a nerve block.

Next week, I might make a call to QScan in Qld. I know radiologists there who do facet joint injections. They would be good to clarify how to improve dx with a joint or nerve block. They also might be able to suggest someone in Sydney. A GPs referral should all that is necessary. If it is CT guided, it may be quite expensive (out of pocket $300-500). If a specialist referred, it might be significantly cheaper.

vosadrian
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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Fri Oct 26, 2018 2:22 pm

CKinnard wrote:You might get a radiologist prepared to do a celestone injection into the hip joint.
That would be very insightful, and similar in clarifying to a nerve block.

Next week, I might make a call to QScan in Qld. I know radiologists there who do facet joint injections. They would be good to clarify how to improve dx with a joint or nerve block. They also might be able to suggest someone in Sydney. A GPs referral should all that is necessary. If it is CT guided, it may be quite expensive (out of pocket $300-500). If a specialist referred, it might be significantly cheaper.


Yeah, it seems a good diagnostic criteria for FAI is cortisone into hip joint capsule. Reduction in pain is a good indicator of a positive surgical outcome. $3-500 is nothing compared to what I have spent so far! I think standard practise in the US is an MR arthrography and cortisone injection.

Appreciate your efforts, and any advice on people to see. If I go see my GP he will just refer to a local Orth. It would be good to give some names of good ones when I see him and get on the right path straight away. I once was referred to a Neuro who just referred me to a different Neuro!! A bit of googling on running forums has given me a couple of names that seem good: Dr Robert Molnar, Dr Michael O'Sullivan. Otherwise it seems many go to Melbourne/Hobart where there are some world renowned surgeons who have treated high level athletes (top 5 tennis players, AFL etc.). They will probably have a 3 month waiting list to see them anyway!
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CKinnard
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Re: Where to next? (Medical practitioner question)

Postby CKinnard » Fri Oct 26, 2018 3:31 pm

vosadrian wrote:Yeah, it seems a good diagnostic criteria for FAI is cortisone into hip joint capsule. Reduction in pain is a good indicator of a positive surgical outcome. $3-500 is nothing compared to what I have spent so far! I think standard practise in the US is an MR arthrography and cortisone injection.

Appreciate your efforts, and any advice on people to see. If I go see my GP he will just refer to a local Orth. It would be good to give some names of good ones when I see him and get on the right path straight away. I once was referred to a Neuro who just referred me to a different Neuro!! A bit of googling on running forums has given me a couple of names that seem good: Dr Robert Molnar, Dr Michael O'Sullivan. Otherwise it seems many go to Melbourne/Hobart where there are some world renowned surgeons who have treated high level athletes (top 5 tennis players, AFL etc.). They will probably have a 3 month waiting list to see them anyway!


I recall you had a MRI of your right hip. I don't think MRA would give more insight, but the latter is preferred for complex cases.

vosadrian
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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Mon Oct 29, 2018 10:11 am

CKinnard wrote:I recall you had a MRI of your right hip. I don't think MRA would give more insight, but the latter is preferred for complex cases.


Right Hip MRI is over 2 years old now, so they may want an update. But if it was screwed then, it is unlikely to be better! The MRI report back then mentioned a labral tear, but did not appear that bad. At the time I had the symptoms similar to now... I think it is worse now, but I have worked out how to prevent it flaring up as bad these days by avoiding things that trigger it.
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CKinnard
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Re: Where to next? (Medical practitioner question)

Postby CKinnard » Mon Oct 29, 2018 12:55 pm

vosadrian wrote:Right Hip MRI is over 2 years old now, so they may want an update. But if it was screwed then, it is unlikely to be better! The MRI report back then mentioned a labral tear, but did not appear that bad. At the time I had the symptoms similar to now... I think it is worse now, but I have worked out how to prevent it flaring up as bad these days by avoiding things that trigger it.


The other thing is when screening for FAI, it is usual to image the hip jt in various positions likely to cause impingement.
Your original MRI (and XRs) may have just been in supine (or standing) with neutral hip jt position.

I also just re-read a few of your posts, and note you said you had lower back, pelvic, hip area pain well before feet symptoms.
That still fits with lumbosacral pathology. When structures in this area are initially compromised, you may just get local symptoms or proximal referral. As the compromise increases, referred symptoms will progress distally i.e. a small disc bulge or herniation typically does not refer below the knee, whereas a more developed herniation can refer to the feet. Many many GPs still use the low back pathology guideline to only request MR when there's symptoms below the knee.

Anyway, I think it is worth persisting systematically looking for an answer. Don't be put off by the indifference or cynicism of health pros.
It's your body. If you had access to a MR machine and 1000 free clinic hours with top health pros, you'd no doubt get to the bottom of it. Many conditions are just so atypical they are unlikely to be discovered within the commercial limits of current health education and consultation economics. see blue text below.

On a final note, be aware FAI is a bit of a flavor of the month diagnosis over the last 5 years. A lot of people have labral tears and FAI dx, then they get talked into surgery, but their symptoms are no different. My view is diagnostic blocks are very valuable in ascertaining the source of pain for this reason.

Twenty+ years ago, GPs used to do more joint injections, but few do now because of the risk of joint infection. But with good sterile technique, it's not an issue. I suppose there's public health cost restrictions on these procedures, and pressure from specialist colleges protecting their turf.

As an analogy, I've seen over 5000 shoulders in my career. Often an ultrasound is done, it shows a bursitis and tendon pathology. An injection is given, and symptoms don't change significantly for 60% of injections! But then I can come along with a protocol of unloading the most likely tendons involved and other structures, and pain eases immediately. A clinical paradox!

The more experienced a physio gets, the more they begin to see similar patterns in different parts of the body (pelvis/hip jt has similar presentation characteristics to the shoulder).
Over time, a more robust diagnostic algorithm can be constructed to incorporate these insights that take many many consults to develop.
Really good algorithms are more likely developed in a high volume clinic with adequate revenues to support older clinicians teaching younger, and interdisciplinary presence (specialists, radiologists, rheumatologists, physios)
Australia doesn't generally have the business volume for such clinics. The US is excellent at this i.e. Steadman Hawkins' various centers.


[an example that drove this home for me was a patient I had last year in California...over 7 years of multiple consults with specialists, multiple abdominal/pelvic scans, three colonoscopies, one endoscopy, multiple blood and feces analyses.

An imaging tech I think is underutilized (she did not have this) for small intestine symptoms is capsule endoscopy (a capsule sized camera with its own light source, takes photos frequently after being swallowed.)

This patient had really been through the mill with chronic sleep disturbing pain, and it had naturally effected her personality. I know many doctors (including those where I was working) thought she had borderline personality disorder and/or hysteria, so they discounted P(organic cause of pain). I've been around long enough to know even mad people can get organic pathology, and that can make them worse! :)

The reason I am relating this story is because I didn't have time in a normal consult to investigate meaningfully if there was something organic in her small intestine causing the pain. This was at a residential health center, and I had the time a few nights later to go to her room, and spend over an hour exploring her abdomen for a cause. To cut a long story short, I ended up clearing her spine, abdomen, pelvis for referred symptoms, then focusing on the small intestine in the region of the pain.

After 2 hours of manual investigation of the small intestine (massage, peristaltic activity, hatha yoga breathing and asanas, diaphragm ex, gradually the small intestine became more compliant and BINGO, I was able to feel a very hard section of small intestine deep deep within where the pain originated from. I worked on it for another hour to soften it, circumscribe its boundaries and shape. - Consult time? 4 hours.

That last hour of manual therapy reduced her pain to the lowest level since the original symptoms. The patient was overwhelmed to finally know there was an organic cause for the pain, and it wasn't in her head as so many of the specialists had countertransferred. The next day I wrote a letter with an illustration of the hard mass, for her to present to various specialists to have the section further scanned or surgically investigated.

Now that woman could have spent another 5 years and 10s of thousands of dollars on standardized health system consults, and not got to the bottom of this issue. ]

vosadrian
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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Tue Oct 30, 2018 2:02 pm

Thanks for the info.

All my MRIs have been supine. I have never seen anything else. I agree that it is doing a scan when I am in the position I have the least problems!!

What I would do for access to an MRI machine and some smart clinicians for a few days. It would cost a fortune of course, but I would pay it. The current approach has cost me a fortune and gotten me nowhere. Given the way things work, IMHO, my only options are:

* Learn to live with it and adjust my life to accommodate the pain. This is difficult because things progress worse, and the situation 10 years from now seems rather dire.
* Keep doing the same thing that has not worked over and over costing more money and getting nowhere.
* Try new things not yet done that are feasible within the current systems I must work within, and hope that one day something comes up and we get to the bottom of it. This is what I am doing now.
* Roll the dice and go somewhere different with different systems and spend time/money with the best the world has to offer. This one is difficult since I provide for a family as well as myself and keeping my family happy is more important to me than my own situation.
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CKinnard
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Re: Where to next? (Medical practitioner question)

Postby CKinnard » Tue Oct 30, 2018 4:33 pm

vosadrian wrote:* Learn to live with it and adjust my life to accommodate the pain. This is difficult because things progress worse, and the situation 10 years from now seems rather dire.
* Keep doing the same thing that has not worked over and over costing more money and getting nowhere.
* Try new things not yet done that are feasible within the current systems I must work within, and hope that one day something comes up and we get to the bottom of it. This is what I am doing now.
* Roll the dice and go somewhere different with different systems and spend time/money with the best the world has to offer. This one is difficult since I provide for a family as well as myself and keeping my family happy is more important to me than my own situation.


I don't want to distract you from persisting with a specialist or GP you have got a good relationship with.
Sometimes, they need to go through a systematic clinical process until they have convinced themselves your condition doesn't fit into a standard pigeon hole. Only then do they start thinking outside the box. This might be also swayed by Medicare and professional college guidelines.

Anyway, if I was in your shoes, and the pain is as you say, I'd persist looking for a solution....and meditate on it regularly to get an intuitive hunch on which direction feels right.

One option - you might phone Steadman Hawkins clinic or that Melbourne clinic, for a recommendation of a specialist in FAI in Sydney.

vosadrian
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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Wed Nov 07, 2018 11:50 am

An update....

So I have seen a Hip Surgeon. Mostly by luck I stumbled across one that is a specialist in hip arthroscopy and FAI hip impingement and does more of this in Sydney than anyone else, having trained under a Melbourne based surgeon who is one of the best in the world. His receptionist was great and I ended up having (another) MRI prior to my consultation. MRI report comes back with FAI and labral tears on both sides. Why did the MRI done 2 years ago not say this? Would have saved me all the effort in this thread! The prior MRIs gave hints of this pathology, but not enough for the doctors who ordered them to consider it as a cause of my symptoms so they were put aside.

So I see the surgeon, and he was very good to deal with. I have heard stereotypes of Orthopaedic surgeons and he was not that. Took the time to explain everything and show me the issues on the MRI. Said the impingement was worse on left, but tearing worse on right and this is common for dominant leg to have worse symptoms. He believe it explains most of my symptoms. He said that I have done plenty of conservative treatment if that was going to help. The tear is not going to repair naturally, and conservative treatment can only calm the flare of pain. The impingement that caused the pain is genetic and cannot be changed conservatively. The only way to fix this and continue life without restriction in hip use is to surgically fix the bone and labrum. So off to surgery I will go. Can only do one side at a time, so will do the more symptomatic side and see what happens and then consider doing the other side. Recovery (for each time) is considerable. I expect to be off the bike for at least 6 weeks and unlikely to make full recovery before 6 months.

I will report back here as things happen. I hope this is my answer. It won't be the first surgery I have had and yet still I am in this thread. Hopefully this is the one that changes things. I am certainly concerned it won't be but hopeful that it will be. I hope to one day start a new thread that might help others in my situation. Awareness of FAI in doctors is low. Most doctors are trained to wait for a hip to turn so bad with arthritis that a hip replacement is required. Hip arthroscopy surgery is new and not well understood as a means of preserving a hip with minor issues to avoid the need for replacement later. Many athletes have used it to return to full athletic performance.
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ironhanglider
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Re: Where to next? (Medical practitioner question)

Postby ironhanglider » Wed Nov 07, 2018 12:22 pm

I have followed this thread without being able to make a meaningful contribution (perhaps the tradition continues...) however the last post does sound encouraging.

I look forward to seeing the end of the thread.

Cheers,

Cameron.
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vosadrian
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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Wed Nov 07, 2018 1:27 pm

ironhanglider wrote:I look forward to seeing the end of the thread.


Thanks Cameron... you and me both!!

I agree it is the most promising lead yet. My expectation is that it will fix some things and some things will get left over. I think some things have been caused by my compensations for the hip and may need separate treatment to recover back to normal. If I can just turn the momentum in my favour I will be happy.
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RhapsodyX
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Re: Where to next? (Medical practitioner question)

Postby RhapsodyX » Fri Nov 09, 2018 1:30 pm

No emoticon for "thumbs up"... but finding a verified issue is always a good thing.

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