My Hip Story
I’ve been an active person my entire life, from camping and four wheel driving, to tramping, outdoor persuits, karate and school sports.
My biggest involvement was karate training throughout my teens, working my way up through the ranks. I do not remember any specific injury or pain while training, but was never particularly flexible in my hips and did struggle to stay in ‘horse’ stance for any length of time.
After being reasonably inactive for a while after I left school I decided to get back in shape and set myself the goal of completing a duathlon. I completed the Special K Women’s Duathlon in March 2006. About a week after the race my left hip was so sore I couldn’t lift my leg to go up stairs and it would ‘catch’ if I twisted the wrong way.
Thinking I’d done something serious I went to my GP who sent me for x-rays to rule out a stress fracture.
Nothing abnormal showed on the x-rays, so I was told it was a sprain. I was put on NSAIDs and told to rest and I came right over a couple of weeks. I got the occasional ‘twinge’ but it wasn’t often enough or severe enough for me to actually realise something was wrong.
In June 2006 I took up mountain biking and really got into it. I was looking forward to my first race, the Rainbow Rage in March ’07. I finally got around to getting clip-in pedals and one day in October I went for a road ride and got my feet stuck in the pedals at an intersection. So the inevitable happened and I fell to my left, landing on my knee and hip. This is where all the problems escalated. The catching and popping became worse, riding my bike caused aching afterwards and even walking long distances became a problem.
Back to the doc I went and I was told I had bursitis. I had an ultrasound that was negative and was prescribed anti-inflammatories and physio. It was my physio who after doing her own assessments including the awfully painful ‘scour test’ asked if I got catching in the joint and when I said YES! she suggested I see a sports doc to assess for an acetabular labral tear. Up until this point I didn’t know how to describe this ‘catching’ of the joint, so found it hard to explain what I was feeling.
The Sportsmed doctor did his exam and said he thought I did have a labral tear and sent me for an MRI Arthrogram. The test came back positive for a small anterior tear and probable superior tear. So the Sportsmed doc then sent me to an orthopaedic surgeon who specialises in hips and can perform hip arthroscopy, Mr Paul Armour.
Radiology Report ~ MRI ARTHROGRAM LEFT HIP 20 December 2006
Eight-month history of left groin pain. Positive impingement test. ? Labral tear.
Informed consent. Gadolinium and Marcain left hip arthrogram. Anterior impingement test positive then negative post-anaesthetic.
There is normal acetabular anteversion. There is normal femoral head neck offset with minimal irregularity at the femoral head neck junction. There are no definite osseous predisposing factors for femoroacetabular impingement.
There is a small focal anterior labral tear (at 9 o’clock in this left hip.). There is linear signal within the superior labrum, between 11 o’clock and 12 o’clock, suspicious for a superior labral tear. The remainder of labrum appears intact.
There is no femoral or acetabular chondral abnormality.
There is no muscle or tendon abnormality around the left hip joint.
1. Small focal anterior labral tear (9 o’clock).
2. Probable superior labral tear (11 o’clock to 12 o’clock).
3. No chondral abnormality and no definite osseous abnormality predisposing to femoroacetabular impingement.
After my consult with Mr Armour, he had the MRI reviewed by his Orthopaedic radiologist to confirm the tear and any other abnormality as the tear appeared very small. The tear was confirmed as the only abnormality, and I booked in my Arthroscopy for Tuesday 19th June 2007. The plan being to look in the joint and smooth out any tears in the hope that my symptoms would lessen, or even better, disappear completely.
Surgery seemed ages away and long days on my feet at work were becoming harder to manage. I was eventually prescribed Codeine for the pain so that I could get around normally and sleep at night, but the problem was I didn’t need it all the time, so when I did need it it took a very long time to kick in and provide relief.
Surgical Report – ARTHROSCOPY & DEBRIDEMENT OF FIBRILLATED LABRAL TEAR 19 June 2007
The patient was placed in the right lateral position and the traction device applied to the leg. A trial distraction was effected with image intensifier control. The hip was distracted approximately 11mm and the position marked. The traction was then released. The leg was prepared and draped in the usual fashion. The joint was entered through three arthroscopic portals. A superior, antero-superior and postero-superior portals were effected. The articular cartilage over the acetabulum and the femoral head were normal. The pulvinar was normal. There was a posterior labral recess. At approximately 10-11 o’clock there was some fibrillation of the labral margin. This was reduced using a radio thermal ablator. No other significant abnormality was identified. There were no tears anteriorly in the labrum. At the end of the procedure 10ml of Marcaine were introduced into the joint and the portals closed with interrupted 4-0 Novafil skin suture.
Antero-superior Fibrillation of the Labrum ~ Bottom Right Image
Post op ~ day 2
Post op ~ day 14
Apart from severe nausea for 4 days post op due to an unknown sensitivity to Paracetamol, recovery went fine. I used two crutches for nearly a week when outside the house and one crutch inside until I weaned down to just one crutch everywhere then none. I had difficulty bending forward for quite some time as to put my shoes and socks on but this soon got easier.
Four months post op and I was itching to get back out on my bike and get active again, but was still getting an ache in my groin, occasional catching and a lot of popping, more-so than pre-op. So I went back to Mr Armour who said it was too early to tell what is going on and to see him at nine months post-op. I Went back to him at nine months post op, after getting a second MRI arthrogram. At this stage I had no groin catching but still had a deep ache and popping. I Had managed to compete in two entry-level triathlons by this stage, so he was happy that I was doing ok. It was at this appointment that I found out I have a slightly irregularly shaped femoral head/neck that more than likely predisposed me to the tear in the first place and is probably the culprit for my ongoing pain. The MRI also showed another labral tear.
Radiology Report ~ MRI ARTHRO LEFT HIP 22 Aug 2008
Arthroscopic debridement of fibrillated labral tear in June 2007. Persisting pain following this.
Prior to intra-articular injection of gadolinium with local anaesthetic, the patient did have discomfort with forced abduction and internal rotation of the left hip. She states that this was definitely improved following the intra-articular injection of local anaesthetic.
There is a linear radial tear of the anterior labrum between 9 and 10 oclock visualised on axial image number 12 . This tear is visible on only 1 slice. This does appear to extend full thickness between the inner articular and peripheral margin of the labrum. It is also visible on the sagittal sequence. There is no displaced labral fragment and no para-labral cyst. The labral defect at this site is slightly more prominent in comparison to 2006.
The remainder of the labrum has a normal appearance.
The hyaline cartilage on both sides of the hip joint is preserved.
The ligamentum teres is intact.
The gluteus medius and minimus tendons are intact and no abnormality can be seen in the peri-articular soft tissues.
The femoral head/neck offset is within normal limits as previously identified.
Small recurrent focal anterosuperior labral tear. No other abnormality seen.
Despite what the radiologists say, Mr Armour is adamant there is a bony abnormality, though he told me that at this stage there is nobody in NZ who can fix the bone problem arthroscopically and that open dislocation surgery was far too drastic for my situation, however he could refer me to somebody in Australia if I so wished.
I decided I’d just give it a bit more time and see how I go.
In the meantime I did my own research into arthroscopic surgeons and came across John O’Donnell in Melbourne, Australia. John is considered one of the best in his field and helped pioneer the arthroscopic technique for FAI treatment. I sent him a letter along with my notes and he replied suggesting I get a 3D CT scan in Melbourne and see him for an appointment, with tentative surgery booked for the same day. He advised against getting the CT done in NZ as the way he does them is different and would require re-doing it.
As my injury is covered by ACC in NZ, all my treatment here is paid for. If I went to Australia, I’d have to pay for flights, accomodation (for at least 2 weeks), surgeon appointments, CT scan, surgery, hospital fees etc etc. so definitely could not afford it.
I continued my research and when looking into getting the scan done in NZ (under ACC) to Mr O’Donnell’s protocol, it was suggested by the head of radiology at Ascot Hospital in Auckland that I visit Mr Haemish Crawford as he performs hip scopes regularly. I contacted Mr Crawford’s secretary and specifically asked if he treats FAI but never got a straight answer. I got an appontment to see him so thought I’d just ask then. ACC were trying to decide whether they’d pay for my flights to and from Auckland and needed a referral from Mr Armour since I’d just made the appointment myself.
When I got a copy of the referral letter, Mr Armour had stated that there are in fact two other surgeons who are better qualified to perform the surgery. This totally confused me, as the last time I spoke to him he told me that NOBODY here could do it and it was at least two years away from being performed competently. The other surgeons mentioned were Mat Brick in Auckland and low and behold, John Rietveld in my home city, Christchurch.
There is a long story regarding the appointment with Mr Crawford, which did eventually happen. The story can be found on my blog. The outcome was that yes he indeed does treat FAI arthroscopically and has done for about two years! He did a quick exam with the usual ROM tests and asked a few questions. I was referred for the CT with 3D reconstruction, which I had done here in Christchurch. The results of which are fairly normal with some slight irregularities.
Radiology Report ~ LEFT HIP CT SCAN WITH 3D RECONSTRUCTION June 2009
Labral Tear.Â Morphology Assessment.
Acetabular Version: Normal, 18 degrees.
Transparent 3D Model AP pelvis: Image 35
Normal acetabular version with no crossover sign.
Axial Rotation around femoral neck:
No significant area of reduced head neck offset or hyperostosis is present although anterosuperior cortical irregularity and reactive sclerosis is present.
Femoral head sphericity:
Internal rotation of the distal femur with respect to proximal: 12 degrees. (righter equals 12 degrees also).
Normal joint space. No cystic change. No labral ossification.
So again the scan was noted as mostly normal, though I was sure I could see that it was not. Thankfully when I saw Mr Rietveld he picked up on the problem straight away. Confirmed the labral tear and confirmed CAM impingement! He recognised that I had done a lot of research and asked what I wanted to do. Options were a) do nothing, b) scope it, c) open surgery. So after being asked if I needed to go away and think about it, I said no, I’ve had plenty of time! Lets do this, I opted for scope.
The surgery had to be approved by ACC and this took some time. I was one of the lucky ones and was covered 100%. My surgery was November 10 2009. It was found that I in fact had no anterior femoral head/neck offset and the labrum was calcified and pretty wasted. The repair could not be performed due to the labrum disintegrating so the damaged area had to be removed. The cam (Ganz) lesion was removed and my hip ROM was tested for impingement and found to be clear. Op notes below (some of it doesn’t make sense and I think this is due to them being dictated).
Operation Report 10 Nov 2009
Mr John Rietveld @ St Georges Hospital, Christchurch, New Zealand.
Left Hip arthroscopy and debridement of labral rim which had some calcification within it, unfortuantely there was no repairable labrum here and resection of significant prominent head/neck junction.
The patient was anaesthetised and the left hip was prepped and draped in the usual manner to give a sterile field. The image intensifier was used and a 2 portal arthroscopy was undertaken. The findings showed that the labrum anterior was pretty much redundant and it was actually really just part of the acetabulum where the ossification within it, there was a small area of calcification in the anterior labrum and the labrum adjacent to this was lifted. I tried to take this down with the knife but unfortunately there was only a couple of millimetres thick and with the calcification it just fell apart, therefore I resected this with the wand. I then inspected the head and found that there was a significant area of chondral damage on the rim, then marked this area where there was a lack of head/neck offset with the wand and then used the burr to resect and recreate a head/neck offset. Following this I ran the hip through a full range of motion both with the image intensifier and direct visualisation and found that it was no longer impinging. I thoroughly washed out the joint, placed some Nylon sutures into the portals followed by dressing.
Below are links to some sites I found very helpful in understanding hip pathology, in particular labral tears. There is a wealth of knowledge to be found at these sites. The forums are especially useful with regular posters who have been through the process of diagnosis, surgery and recovery from a variety of hip disorders. Information on the best surgeons, hospitals and helpful recovery tips can all be found and you can ask all the questions you need.
If you would like to talk to me or ask me any questions, please contact me.