Worth the Time or Not

Recently, some of my hip consultation "clients" (friends of friends, cyber friends, referrals, etc) have asked what were the things that helped me most to recover from my surgeries and what was a waste of time. Its a good question and one I couldn't really have answered until fairly recently when I knew that my hip was actually recovered. I do have some pretty strong opinions when it comes to recovering from hip surgery and I certainly have a fair amount of experience unfortunately so for what its worth, here is a summary of what worked and what didn't.

Worth the Time/Money/Brain Damage:

• Swimming -- swimming laps with or without a pull buoy between your legs can really help get the hip moving while still providing a non-weight bearing environment in which to heal. Its important not to swim too aggressively or too early -- I would say not until 5-6 weeks post-op and then only for 15-20 minutes to start. Even 8 months post-op my hip felt good each time I swam.
• Staying active -- even when you are flared up and miserable, it is important to remain active so that the inflammation does not just accumulate and worsen -- spinning on a bike, walking, swimming lightly all help to get the blood flowing and lessen the inflammation. Lying in bed or on the couch does not regardless of what your doctor might believe.
• X-C skiing -- if you happen to live in a place where this is possible, I really found this helpful to build strength in my glutes and hip flexors and keep the joint mobile.
• Trigger Point Dry Needling - this is only available in some states as it requires a specific certification for PTs but it has been very helpful in reducing the pain in and around my hip/quad/IT band/glutes. It hurts but no more so than your hip on any given day.
• Accupuncture -- when I was at my worst this really helped reduce my pain at least temporarily and give me a mental break from the misery for 3-4 days. If you find a skilled practitioner, accupuncture can effectively shut off your pain receptors temporarily and provide some relief.
• Yoga - it is important to stress that I did not begin yoga again until about 6 months post-op after my second surgery and I had to push through some pain for the first 8-10 classes or so but it definitely helped return blood flow and stimulate healing in my hips. Deep stretching isn't a great idea for FAI hips but building core strength, balancing poses and working on alignment definitely helped me.
• Light Strengthening Exercises -- As some others know, I am not a big believer in extensive physical therapy routines after hip scope surgery. I know that Phillipon and his protege around the country strongly believe this is essential to a full recovery but having spent the months after my first surgery trying to diligently follow the protocol and ending up much, much worse off for it, I firmly believe that Dr. Sampson's approach is a much better way to go. Bridge exercises on your back, some easy leg lifts and later on some squats and balance ball work can help tone and strengthen the area. But I was never especially diligent or consistent with any of those and mostly just walked and biked and I still recovered.
• Cortisone injections -- some people are anti-cortisone but I have had good success at least initially with cortisone. After all, its just like liquid advil right targeted right at the bull's eye but in a much higher dosage. I've had 3 in 18 months and I think the effectiveness is less each time but the first one certainly helped drastically.
• PRP injections -- aka Platelet Rich Plasma injections. This is a newer therapy in which the patient's own blood is taken and spun in a centrifuge to separate out the platelets and then re-injected into the injured area to stimulate healing. Platelets have long been used for wound healing after abdominal surgeries and are now being used more routinely for soft tissue sports injuries. Phillipon now injects all of his patients with PRP while they are under during the hip scope and some other surgeons are beginning this practice too. There isn't enough evidence yet to say whether the injections actually help the cartilage or labrum but it appears that the soft tissues of the joint can be assisted in healing. I had one injection into the labrum and one in the muscles around the joint and it definitely seemed to help on some level to bring some healing to the area but I wouldn't tout this as a magic pill either.
• Surgery with an experienced surgeon -- this should really be at the front of the list because it is so damn important. My first surgery failed because I went with a local surgeon who graduated high school approximately 3 years before I did and had done less than 40 of these surgeries. Go to the most experienced surgeon you can afford even if it requires going out of network and pledging your first born child as collateral. Do your research online with the FAI yahoo group or other online forum (there is another good one on Runners' World online) and find out about the top national surgeons or at least the top in your state. Ask who they've trained under, how many surgeries they've done and what their success rate. This is your body and your health so take the appropriate time to make sure you are making the right decision.
• Time -- as cliche as it is, I must mention this because it is truly the magic pill when it comes to recovery. Not 3 months or 6 months -- more like 8, 9 or even 12.

Not Worth It:

• An Ice machine -- I never thought it helped at all because I really couldn't get it that cold and I think raw ice in a ziplock directly on the area or wrapped in a washcloth if you can't stand the cold is a much better option. I continued to ice my bad hip up until about 9 months post op as needed - usually before bed which helps to reduce inflammation the next day.
• The CPM machine (continuous passive motion machine) -- this was definitely not worth it at all and it only resulted in extensive brain damage on my part. The six + hours a day that I was supposed to spend in that ridiculous medieval torture device were unrealistic and worthless. Walking and spinning on a bike were far more helpful in breaking up scar tissue and getting the blood flowing to the area.
• Active Release Therapy (ART) - I know some people swear by this but it didn't help me at all and only aggravated my sore hip by bending and contorting it into unnatural positions with too much flexion. Just my two cents.
• Chiropractic -- I'll say up front that I have had success with chiropractic for other sports injuries including IT band issues but its not going to do anything to help your hip heal or be a substitute for surgery.
• Osteopathic manipulation -- Yep, tried this too. I had one practitioner confidently say that labral tears heal on their own with some manipulation. Nope -- flagrantly not true.
• Rolfing -- not even worth mentioning other than this didn't do anything to me except infuriate me that I'd spent another $100 out of pocket on a treatment modality that didn't work. That and the fact that the practitioner told me my hip pain was actually coming from my large intestine. True story.
• Stem cell injections -- not only can I provide anecdotal evidence that this absurdly expensive and clinically un-proven therapy does not work but I also have actual physical evidence in that after 6 months and 3 rounds of stem cell injections when my surgeon went into my hip for a revision scope he found the same hamburger meat cartilage that had been there before and it was actually even worse. While a great idea in theory there is just no way yet to get the stem cells to the right place in the joint to repair damaged/lost cartilage. They just kind of float around in there aimlessly. In my opinion.
• Its important to mention that these modalities might help other injuries or other people - especially if you believe they will help -- but they just didn't help me and they aren't going to solve the problem of a torn labrum, hip impingement or damaged cartilage in the joint.

A Little Greed is Good

If I even have any blog followers still out there I feel it worth saying initially that my 6 plus month hiatus is really inexcusable and if you are one of these poor souls recovering from hip surgery and looking for a glimmer of hope out there in the Universe I have done a terrible job of providing for you. However, I also have a well-justified fear when it comes to my hip of putting good things down in writing and eating my words later. This fear is so strong that it has taken me all summer and fall to actually say out loud to anyone who asks that, yes, my hip is doing much much better and appears to be holding steady at long last. Previously, to anyone outside my immediate family I never wanted to commit to an answer if it might mean that I couldn't change my mind later. But after turning a corner in late spring and enjoying a summer of unrestricted activity including hiking, mountain biking and even some running I am finally letting my guard down a little and accepting that this actually might have been a successful surgery. I still had a resurfacing surgery date for September 1st that remained scheduled until mid-July which is a good indication of just how little confidence I had in my hip after this whole ordeal.

The big test was the 10-day trip of a lifetime to Idaho in late June where we spent a week rafting the famed Middle Fork of the Salmon River with 18 of our friends and I hiked my way up and down the steep canyons of the Frank Church Wilderness and lifted heavy gear in and out of our raft multiple times each day. I didn't even notice my hip the whole week including after the 15 hour drive to and from Boulder to Stanley Idaho. It was an emotional test of sorts too -- to finally be able to feel normal again amongst my friends and not always popping pain killers and reaching for flexor patches in the middle of the night to make it through the trip. I didn't pass up a single opportunity each afternoon when we made camp to bushwhack my way up the canyon walls to look out at the vast snow-capped Sawtooths and revel in my good fortune and remember what it feels to be alive.

Many have asked what happened to finally after more than 2 years allowed me to turn this corner and how did I know I was actually getting better. I don't necessarily have an answer to that except to say that Time has been the most essential element along with an almost violent stubbornness on my part to get my life back. I pushed my hip pretty hard all of last year and just refused to accept that I had to give up so many of the things that brought meaning and joy to my life. Some have suggested after all that I have been through that I just accept a more limited life and agree to give up some of the things that might have lead to my injury. That seems reasonable enough but frankly there hasn't been anything reasonable about the two years it took to recover from this injury and after all is said and done I still feel most fulfilled when spending my time running trails with my dog, hiking the high country and skiing powder in the Colorado backcountry on a bluebird day.

My hip could last 2 years or 5 years or potentially even longer - I really have no way to gauge it and won't bother trying. For the time being, I plan to live large with my hips and be a little greedy. Many times during the last two and a half years I pleaded with the hip gods that if I could just get back to some biking and hiking I'd be content and would behave. Well, as the title of this post suggests and as I should have anticipated, prolonged deprivation makes some (reasonable) people appreciative of what they have while the other more entitled of us like myself tend to get greedy and want it all. Life is short -- do what makes you truly happy, take risks and learn to live with the consequences when things don't go as planned.

And so it goes as I attempt to get back into trail running despite a bum knee, a weak butt and a hip that has undergone two extensive surgeries, roughly 8 different injections and a thousand hours of poking and prodding by numerous physical therapists. Greed is good.

My Hip Really Hurts

Today at least, and yesterday and alot last week. There is absolutely no rhyme or reason to my hip pain except for maybe some strange cyclical phenomenon that I have yet to be able to identify in any meaningful way. I have good weeks in which I don't have to think about walking the dogs or sitting at my desk and there are other weeks where I wake up feeling sorry about the 10 minute walk around the pavement the dogs are going to get that morning. And then I sit at my disk all day and poke and prod my hip because its so pissy and wonder if I should get up and go to the gym to try and get some blood flowing or if its better to rest...I have no idea on that one. The ups and downs are what I've consistently written about in the last year and a half of this blog and are what need to stabilize or else. I can deal with a few days every month of pain but I generally do not have any pain-free days and the majority of days I have a fair amount of pain ~ its just that now 6 months after my last surgery my hip has "healed" enough to where I can push through pain to do some of the things I want to be doing. Not that pushing through pain is really any fun though, especially when its not "good pain". Its the bad kind of pain that means something is wrong and even if those neuron pathways and pain receptors have all gotten a little too sensitized in the last 2 years they are still there telling me that I'm not supposed to feel this way -- this isn't just old age or over-doing it or whatnot.

I had an interesting conversation with one of my PTs yesterday about the role of the nervous system in all of this after living in chronic pain for 2 years. He really believes that there is alot of re-training that needs to go on in order to de-sensitize my nervous system after prolonged periods of intense pain. I am going to do a little more work in this area for sure but I still whole-heartedly believe that once you remove the source of the pain and replace it with a healthy joint all those nervous system breachs are going to work themselves out over time. I know that people living in chronic pain have been able to help themselves with imagery, meditation, etc and that just in the way atheletes can use imagery to push their bodies to great lengths we can also use our mind to control and help alleviate chronic pain. I do know that when I get really down about being in pain it leads to a viscious cycle of depression, feeling over-whelmed and hopeless, exhaustion and more pain. I do know that when I have a really good few days and do something I haven't done in a long time the pain doesn't seem nearly as sharp and concerning. But this isn't rocket science here folks and as much as I'd like to believe I can focus my thought patterns better to decrease my perception of pain my mind also knows that I've got a hip with a lot of very damaged tissue that looks a bit like hamburger meat and may just not have any more life in it. I suppose I need to really endeavor to do EVERYTHING I can in the next 3 months to help my hip by strengthening the muscles around it as much as they will allow, rewarding it for good behavior and working on these nervous system issues. Then, I will really know that I gave it my best shot whatever happens.

I don't want another surgery. I really don't want another surgery. Not even a little. But as I've said ad nauseum I won't accept that this is as good as its going to be. I made a promise to my ginormous puppy that I wouldn't let another year go by without being able to really spend some quality time in the woods with him and I'm going to keep that promise whether or not it requires another surgery.

Following Up

Back to San Fran for a whirlwind day trip to see Sampson for my 5 month post-op follow-up appointment. That's a long way to go for a 30-minute appointment but I felt that in flying out to see my surgeon I was dutifully giving this last surgery my utmost effort and encouragement...even if Dr. Sampson's painstaking work ends up getting paved over this summer. We looked together at my recent x-rays and the pictures from my scope and discussed my expectations and timeline. He didn't really have anything especially novel to say that I didn't already know...my right hip is effed up pretty good and will require some significant cartilage re-growth to fill in the potholes of cartilage loss. I'm still fairly certain that re-growing cartilage via microfracture has a slim to none chance of actually working but I respect that Sampson believes otherwise. (I'm certainly not alone in this belief either as evidenced by the multitude of people with metal hips who previously endured microfracture surgery).

Dr. Sampson also asked if we could talk "bluntly" about my biological clock and getting pregnant with my crapped-out hips. I told him that while I did want to get pregnant I have been more concerned with making it a full week without painkillers and still feel like adding 25 lbs to my already-slight frame would be asking for trouble. He advocating getting knocked up now and then if my hip still isn't fixed post-baby I can consider more invasive options. Easy for him to say since he will never be sentenced to 9 months of hip pain without pharmaceuticals but I appreciate his sentiment. All in all, the best part of my 15 hour trip to the West Coast was walking through the leafy neighborhoods of San Francisco for a few hours and meeting up with an old friend from law school for some excellent Thai food (in Japantown).

As for my vacation to Costa Rica the hip actually cooperated decently well I'm sheepishly willing to admit. It has nothing to do with "happy hormones" as my mom calls them because I've been in horrendous pain on plenty of other vacations. I just think my hip is scared shitless to misbehave because it knows there is now a firm expiration date (August 4th at the moment).

I can't quit you

My hip is like a bad boyfriend. Every time I take you back you disappoint me worse than the last time. You manipulate me and deceive me and make me think things are going to be different this time. You raise my hopes to monumental heights and then you let them all come crashing down in a perfect storm of despair and self-doubt.

I'm really over you. Really. Instead of sitting at home feeling sorry for myself and wallowing in my despair I'm choosing to say FU hip and pop a bunch of painkillers and go on with my life. I skied 3 miles into a backcountry hut last weekend on Willow Creek Pass in agony. I even carried a modest pack of gear on my back (Brian carried the other 48 lbs of it) as I gritted my teeth and cursed you throughout the 2 hours of moonlight skiing to the hut. Better to be in pain in the mountains with friends than in pain at home on my couch alone.

Hip: you've got a mere 5 months left on your contract and if you don't miraculously improve your performance by then you're going to get dumped and permanently replaced by a newer, more mature model capable of a committed relationship.

Trying to be a good patient

I haven't written in a month because I was actually on a wild spending spree with my hip. My last flare-up was, well, exactly a month ago and I knew with each passing day that I was due for another and like a rogue wave gaining momentum at sea my hip was going to crash at some point. I have really pushed my hip for the last month and its actually responded decently well to the stress. I have in fact done a number of activities which a sane person would find quite hard on the hips including two days of backcountry telemark skiing with uphill skinning of around 2 hours as well as some fairly regular skate skiing. I definitely could not have even thought of such things a year ago or even last fall so I was thrilled that this was even something I could attempt let alone achieve.

In Steamboat for Brian's birthday we decided to do a mellow tour on Rabbit Ear's pass and with some strange aligning of the stars everything seemed to come together to reward me for my patience in this absurdly tedious and exhausting Year 2 of the hip. Most of the climb was barely more than a nordic tour until the last push above treeline. But the powder was magnificent and I was grinning my way down the slope with five or six smooth tele turns the likes of which I haven't had in almost 2 years. I wondered whether this was breaking some kind of post-op rule considering I was barely 3 months out (ok, I am fairly certain of that) but I wouldn't have done it if I hadn't thought my hip was going to handle it ok and it did. Last weekend I tried again and was in a bit more pain but the climb was substantially steeper and we were forced to snowplow our way back through icy trees for nearly 30 minutes and that likely didn't help things. All the same, my friend Julie exclaimed, "I can't believe you can do this? This hurts my hips!" As frustrating as this whole experience has been I have to admit that I have recently been wildly active for having had bilateral hip surgery on October 29th. Sure, I've been pushing through some pain throughout the last month but it has been mostly manageable pain and not spend-the-weekend-on-the-couch pain.

Thankfully, the surge in activity happened to coincide with hearing from various elite surgeons that I was not yet an ideal candidate for resurfacing. Had I still been in miserable pain and stuck on the couch I would have been despondent upon hearing that Dr. Su thinks I should "give the microfracture more time". Interestingly, Dr. Gross said I was a candidate and offered for me to schedule surgery this April but also said I was not so far gone and he couldn't put my chances of success at 95% because there was about a 20% chance that I would still not be happy with my hip because when all is said and done its still a metal hip. I've long since accepted that I'm going to have a metal hip at some point so I don't necessarily agree there. Then there is the whole technical issue of having too much cartilage which could potentially mean that there is not enough blood flow to the femoral head from arthritis to allow the implant to properly grow into the bone. The absolute worst thing in the entire freaking world would be if I resurfed too early and it failed -- I would never forgive myself. If my resurfaced hip is going to fail and need to be revised to a THR I want to know that it was because I am incredibly fucking unlucky as part of that 4% whose devices fail and not because I jumped the gun on the surgery. Even if that means putting up with my psychotic hip for another year or three. On top of everything else, I'm also not going to give up our 7 day float on the Middle Fork of the Salmon this summer to be recovering from yet another hip surgery. If only I was as successful with hip surgeries as I apparently am with river permit lotteries!

Now that resurfacing is temporarily off the table the stakes are much higher such that every time I have a flare-up I can stomp my feet and throw shit at the walls but I cannot fall back on the comfort of knowing I only have to suck it up another 3 months until I can get a new one. I also cannot treat my hip as a short-timer and abuse it because its going to be retiring soon anyway. That is almost certainly going to be my greatest challenge. My fear of all fears is that I will push off the surgery and in the midst of trying to start a family my hip will fall completely apart again. But, as Willy Wonka says, there is no way of knowing which way we are going.

Really? No, Really?

You have got to be kidding me Hip. All I asked for was 5 days on a beach in Mexico. There was going to be plenty of tequila to help you get through it and alot of lying around and even swimming which you generally like. There was never any mention of para-sailing or horseback riding or even long walks on the beach. I would never have been so presumptous at this point. I even bought a tacky suitcase with rollers so you wouldn't have to do any hard labor lugging a mere 12 lbs up a flight of stairs. I admit to pushing you a little the week before we left but nothing out of the ordinary -- just a little spinning and some cross-country skiing. I thought you were gonna cooperate as we approached the 3-month mark. But no, you had other plans indeed. Not being able to walk down the beach was possibly understandable given that you generally don't like un-even surfaces. But making me get a taxi to go 1 mile into town to SHOP of all things is pretty outrageous and insulting. I don't even LIKE to shop you fuckwad. In any event, you may have seriously pissed me off but you didn't ruin my vacation thanks to about 4 daily rounds of margaritas before 5pm and alot of tacos, chili rellenos and cloudless blue skies.

But, I will grudgingly acknowledge that you did give me 2 weekends of moderate fun ski touring a little (albeit with the help of my close friends Flexor, Voltaren and Tramadol) at our cabin in Winter Park. Elliot and Phoebe thank you more than I do in fact because they got a few hours of fun in the snow instead of prior ski seasons stuck in the parking lot at Abasin.

Just wait Hip. I've got big plans for you. You're not even gonna know what's hit you and you're so gonna wish you had cooperated more when you get a big-ass hammer smashed into your ugly little socket and a nice metal straightjacket for the rest of yo' life BITCHES.