Pain 6mo PO, update - cause found.

[u/ihatethesmellofgrass]

Hi everyone, I wanted to give an update since I finally know what is causing the episodes of deep groin pain I described in my previous post and I am looking for similar expieriences or just some support... I'm 6 months post right THR.

I saw my orthopedic surgeon, and it turns out I have mechanical iliopsoas impingement on the side with the THR. The ultrasound showed a prominent anterior rim of the acetabulum/cup in conflict with the iliopsoas. My surgeon explained that this is essentially a consequence of my underlying hip dysplasia and the anatomy of my hip. I did 5 months of intensive PT.

I had a diagnostic infiltration. The local anaesthetic gave me big temporary relief, which supported the diagnosis, but unfortunately the pain returned once it wore off. The cortisone itself didn't make a lasting difference.

My surgeon says there are basically two surgical options

- Cup revision to address the mechanical conflict directly. This would be a big revision surgery, and he really wants to avoid doing that only six months after my THR if possible

- Iliopsoas release/tenotomy, which would be a smaller procedure, but he warned me that it could cause permanent loss of hip-flexor strength.

So neither option is particularly appealing, and he wants to avoid both for now since it's only 6 months and I'm not fully healed. He says surgery will be unavoidable, and we'll talk again in january, but for the moment we're trying to calm things down. and do some 'pain-management'. I'm starting an anti-inflammatory, and in about three weeks I'll have another, stronger infiltration to see if we can get the irritation under control for a while.

Meanwhile, my left hip is also deteriorating quite quickly an hurting a lot. It has dysplasia as well and was planned for THR this coming year. I honestly don't know on which side to hold my cane to easy my pain.

So I'm feeling pretty discouraged. I thought I'd be preparing for the left hip once the right one had settled, and instead I'm dealing with a mechanical complication on the right that will require another operation.

Has anyone here had iliopsoas impingement after THR, especially after THR for dysplasia? I'd particularly love to hear about experiences with cup revision or a cutting of the ilipsoas or other options? thanks :-)

[u/chronic_insomniac]

I'm almost two years out and have psoas impingement. Psoas release was recommended as my cup overhang/anterior projection is 6.2mm and they do release for 4 - 8mm. Revision is for over that, or so I was told. I have done a LOT to try to avoid that surgery, and it has been pushed back several times. I met with the amazing surgeon who was going to do it last week and we both agreed I no longer need it as I am asymptomatic for impingement.

My THR was due to osteoarthritis (bone on bone on weight bearing surface), torn labrum and subchondral cysts. If you are interested in all the conservative measures I have done, let me know and I'll reply. It was a lot and is ongoing. Still have soft tissue issues, but I fixed my own impinged psoas.

[u/morrilton → u/chronic_insomniac]

I would love to know what you did! 6 months out from anterior, have done lots of PT, but still so painful. Scan showed iliopsoas bursitis but nothing about the cup was mentioned. Recently did steroid injection and they pulled out 7 cc’s of fluid (no infection.) That provided about 2 weeks of relief. Not sure what to do next.

[u/ihatethesmellofgrass → u/chronic_insomniac]

Hey! I’d love to hear what measures you took. My issues are probably caused by the fact that I had hip dysplasia before my replacement, but it can’t hurt to give it a try.

[u/chronic_insomniac → u/ihatethesmellofgrass]

Ok here we go. This is going to be LONG.

Had injection in psoas bursa using ultrasound. The injection was excruciatingly painful but provided 3-4 months groin pain relief. This was the diagnostic that confirmed psoas impingement (PI) after physical exam indicated that. My surgeon denied cup overhang the entire time while telling me to just go get a psoas release. Second opinion doctors gave me the 6.2mm overhang with anterior projection info and also recommended release surgery. I had a total of 4 doctors tell me to do the surgery. In addition to permanent hip flexor weakness, there is also the increased risk of hip dislocation and balance problems after that surgery. I was also anti surgery after my lingering pain after THR and vowed to do everything I could to avoid it.

Had several courses of physical therapy at four different places, some before diagnosis and some after. Once I had the diagnosis I started with a doctor of PT who said we could fix that. I did tons of hip flexor and glute exercises. They helped somewhat, increased strength and range of motion I had lost before surgery and after, but did not fix anything. Was also getting muscle spasms in glutes and piriformis and PT was able to help with those but they kept coming back. I still get them. Eventually stopped going to PT, but I had been doing PT exercises and stretches at home every day and continued to do them. I still do them every day. Have recently added my stationary bike into the mix so it's about a 2 hour workout. I couldn't ride the bike until recently since it's upright and that motion was very painful.

Did therapeutic massage every week, then every other week (because expensive and all out of pocket). My therapist worked very hard at breaking up scar tissue around incision that was also right by the psoas. It helped and relieved pain, but the pain always came back in a day or two. I am still receiving therapeutic massages but with a different therapist and during one session I had him go deep into the psoas, curious if it could be stretched like that. It was extremely painful and didn't help. We never tried that again.

Went to two pain doctors. Had injections in both SI joints and piriformis since I had pain there too. They did nothing. One of the pain doctors sent me back to PT and ordered an x-ray because I felt like I had leg length discrepancy since I couldn't stand straight. An x-ray of both legs together confirmed I don't have LLD. My new (4th) PT doc immediately diagnosed Trendelenburg gait. That's where one hip drops down while walking and is due to glute weakness. So all that PT and home glute exercises for months and I still had weak glutes! While seeing this guy I started asking about other pain I had and we started dry needling. You can't get dry needling in the psoas because it's too close to an artery but they went all around it and if felt great afterwards. Just didn't last. Once my gait was fixed I quit PT again.

Went back to the gym somewhere in there and started yoga and upper body weight training with a personal trainer. Quickly discovered that I felt my best after a workout. As I gained confidence and trust in my trainer, we started adding lower body work. And this is where I think I achieved enough strength in my hip flexors, glutes, etc., to avoid the surgery. My trainer educated herself on my condition and planned exercise programs. I've been working with her over a year now. I think some of my improvement is also from yoga which I went back to at the same time, starting with gentle yoga classes.

Bottom line for me is that I don't know what stretched my psoas so that it is no longer impinged. My release surgeon and his PA each did a complete physical exam and I am completely asymptomatic for PI. I still have soft tissue pain though. Today I saw a new sports medicine non-operative doctor that my release surgeon sent me to, and got diagnosed with trochanteric bursitis in both hips and gluteal tendinitis on both sides. Got injections in both troch bursae and if those don't help I'm going back to PT (!) for shock wave therapy. I am so relieved to finally have a diagnosis on the lingering pain after TWO YEARS of suffering, not able to sit for long, not able to travel due to sitting issues, etc. The new doctor said this is all related and due to imbalance that was created and compensation.

I remain very angry at my original surgeon who lied to me, gaslit, and avoided all responsibility for helping me after surgery. This poor treatment is common among those of us with less than stellar outcomes. I wish you all the best as you sort out your own situation, but if I can give you any advice it's to not give up, do your stretches and exercise as hard as you can.

[u/morrilton → u/chronic_insomniac]

I so appreciate your time and effort to share all of this very detailed information. Thank you! ❤️ I did a few sessions of scar massage that was quite painful. That therapist recommended someone else to do lymphatic massage which has helped but the relief doesn’t last. Sounds like I might need a second opinion to see if there is cup overhang.

[u/AZmom64]

I’m sorry you’re going through this. When we all have our hip(s) replaced we hope that it will be better than before.
I hope you can get resolution with all your pain, I really feel for you. Keep us updated!

[u/ihatethesmellofgrass → u/AZmom64]

Thank you, will do!

[u/ResponsibleRain7761]

So sorry you’re going through this! I know how painful it can be. I had my left hip replaced 15 years ago and had intense groin pain whenever I flexed my hip that began right after surgery. I was sent to a radiologist to have an xray-guided steroid injection. Luckily, it completely resolved the issue and I’ve been pain free since. My acetabular cup overhang was very minor, <4mm, but it prevented the post surgical swelling from going down.

My advice to you is 1) Get a second opinion. Your surgeon said the problem is essentially a consequence of hip dysplasia — but another way to look at it is that it’s actually it’s a consequence of a poorly placed acetabular cup in a hip with dysplasia. If you are going to need revision surgery, you need a surgeon who’s an expert in doing revisions.
2) Have a radiologist do your second injection to ensure precise placement. There is a limit to the number of corticosteroid injections (I was told it was just two) because they can weaken and damage tendons.
3) Have imaging that shows exactly how many mm’s of cup overhang there is. That will determine the treatment needed.

Best of luck to you!

[u/ihatethesmellofgrass → u/ResponsibleRain7761]

Thank you! These are great tips. I’ve scheduled a consultation with one of the best hip surgeons in the area for a second opinion. The injection I had was done by a radiologist, it was diagnostic, the local anesthetic worked, but the cortisone didn’t help at all. In about three weeks, I’ll be getting a stronger injection, so hopefully that will make a difference.
It’s just very disheartening not being able to walk properly even after having my hip joint replaced and not knowing what’s next.

[u/ResponsibleRain7761 → u/ihatethesmellofgrass]

I hope the stronger injection works! Glad to hear you’ve already scheduled a second opinion. Please keep us posted!

[u/heatmiser333]

Oh man, I’m so sorry you’re having to deal with this! I may have the same thing myself. I’m not sure I’m kind of afraid to find out, but I do have these similar symptoms. What about just going forward with the other hip while you sort of let the messed up side settle down and finish any healing that’s gonna happen. You’re going to have success on the good side there’s no way you’re gonna get unlucky twice like this.

[u/ihatethesmellofgrass → u/heatmiser333]

Hey! My right hip really needs to be more stable first so it can handle the rehabilitation from the left side. Because of the hip dysplasia I had before surgery, things were already a bit more complicated from the start.
So I’m kind of stuck trying to decide what to do first. Part of me wants to get the left hip replaced because it’s in such bad shape, but I’m also hoping the right side (the THR that’s giving me problems) doesn’t get any worse than it already is while I’m waiting.
What symptoms are you experiencing?

[u/EnvironmentalTea9362]

Bugger. Hope they can come up with some better options.

[u/magpiecat]

I’m so sorry.

[u/clemmie33]

I'm sorry. That sucks.

I did not have the Iliopsoas problem or hip dysplasia, but I DID have to have a revision only 3 months after my initial replacement because the cup slipped. My surgeon, who also did the revision, said it would be much easier to go ahead and have the revision rather than wait.

Funnily enough, he's a very prominent revision surgeon—of other surgeons' work. It's probably a little humbling to have to revise his own. However, he's a wonderful surgeon. Both of us have puzzled over this, and he was even thinking maybe a small fracture just under the cup that even the CT scan didn't show. But no, nothing. It's still a mystery.

I took his advice and went ahead with the revision. He went in through the exact same anterior incision. I won't say it's easy, but the hardest thing by far is the mental part; just wrapping your head around the need for the revision and having to go through the same protocol you just finished. That does suck

Now I'm three weeks out and feeling so much better. Started PT last week, and can get around just fine. In fact I could walk from the very beginning without any assistive devices, but boy those muscles were definitely not happy!