Health Organization for Pudendal Education

I went to see a nationally (U.S.) renowned arthroscopic hip surgeon for FAI/labral tears yesterday - well I saw his NP (nurse practitioner) because I was trying to get in before the end of the year! And drumroll.....I have a labral tear with possible impingement (they said they can't always tell this for sure until surgery) on my left hip (worst SIJD/PN side) and likely on my right hip as well - though we didn't do an MRI on this hip because they basically address one hip at a time. I also had an injection into the hip which took away my groin pain while the anesthetic is in place. The injection was done under ultrasound and was so easy - nothing like any of the other blocks I've had. No pain today either!

While I am glad to have maybe one more piece of the puzzle, I am thoroughly confused and don't really know where to go from here (granted I have not done as much reasearch on hip issues as I have SIJD/PN). Th NP told me to see how I feel in 2 weeks after the steroid has kicked in and that a labral repair arthroscopically is not necessary that damage to the articular cartilage takes a LONG time so the surgery would only be to help my hip (aka groin pain). I am confused about this because other things I have read led me to believe that if the labral tear is not repaired that it will lead to needing a total hip replacement one day. Of course this NP knew nothing about SIJD or PN and said that surgery will not help with those things. I tried to bring up the study with Dr. Coady and Dr. Coleman, but I dont' have any "proof" of their findings....does anyone have any access to reserach about the findings between PN/SIJD and labral tears? She said that the only thing surgery will help is whatever pain the injection took away, but obviously my PN and SIJD didn't develop overnight. Surely years of biomechanical dysfunction would not be fixed with a hip injection! But then again surgery might not fix it either.

I will follow up with her again in 3 weeks and meet with their PT (who will know nothing of PN I'm sure). I'm hoping in the meantime to do a lot of research and if I think arthroscopic surgery is the way to go then find the research needed to persuade my surgeon to agree to try it. I am not naiive enough to believe that all my pain will be gone after surgery, but at the same time if I dont' fix the mechanical issue with my hip, how will I have the chance at getting any better? I know there are people who are living normally with labral tears and don't even realize it, but I'm not living normally - I have a lot of pain and am very debilitated. My only option left is to try PN decompression which I dont' think is the right thing to do. Granted my groin pain varies in intensity and often the SI/PN pain seems more debilitating, but our brains only let us process so much pain, right? I do not thoroughly understand labral repair yet and I knwo there is a risk of worsening PN symptoms with it. I am also concerned as I have some degree of ligament laxity and central sensitization (so I've been told) so I'm not sure how surgery would affect those things.

I do think a labral tear makes sense as to the cause of my initial symptos which were pelvic floor/pain with intercourse symptom, much more so than PN (and my PN has never been typical - no bowel/bladder issues and my worst pain is really just medial to the ishcial tuberosites coming from the obturator internus). This also makes sense to me why the botox and ESWT were such horrible experiences for me due to the instability in my hip. The NP didn't really seem to think that labral tears cause such great hip instability though so I am confused. Wished I could have seen the surgeon himself!

Not sure if this will help faith have a power point presentation, entitled
The Correlation Between Hip
Dysfunction and the
The Pelvic Floor
Stacey Futterman MPT, BCB-PMD
Beyond Basics Physical Therapy
Cant seem to upload it but could e it to you. It isn't a paper tho'.
Glad you have another piece of the pelvic puzzle, sorry it is proving to be such a puzzle.
Take care
H

Hi helen and faith

Faith I too have a labral tear and my worst pain is exactly where u say yours is. I too have never had bowel or bladder issues just pain pain and pain. I am currently under the care of dr struan coleman for the labral tear and fai. If u would like to talk pm me.

Helen I would be very interested in the presentation if I could email it to me as well. I will pm u my email address.

Diane

No problem Diane.

HI Faith,
This sounds strange, but I am so happy that you have been diagnosed with a labral tear! No one wishes more issues upon you, but this is a cause of issues and not another problem. I know it seems overwhelming, but I have long thought that your symptoms sounded like they originated in your hips. Make sure as you are investigating surgery that they check for hip dysplasia because that can affect the success of a scope. I will look for a link to Dr. Coleman's study. I'm not sure how far along they are in it. Anecdotally at least, it seems to be helping some of the women I've talked with. The last time I talked with Beverly, 8 weeks after her surgery, she had no more PN pain unless she wore tight pants. However, as you noted, it can take up to a year after surgery for the muscles to readjust and stop abnormally compensating and pushing on the nerves. You would need lots of orthopedic pt to work on that. Is that available where you live?

Don't worry too much abou the OS and PT not knowing much about PN, as long as you know they are excellent medical professionals in the orthopedic field, that's all that matters. You can work with the PT to do exercises that do not aggravate the PN more. That's what I've been doing, and it seems to work. It's a big mind adjustment to go from Pn-focus to hip-focused, but its great because people understand when you have a hip issue. I'm glad to see that you are on hipchicks, I am too under "Jackie S" and the ladies there are amazing. I hope that this is the breakthrough that finally helps you relieve a lot of your pain.

Big hugs,
Jackie

Hi Faith,
All of this is overwhelming I'm sure, but I know you will research it. At least the MRI isn't a "guess", or a "well maybe", it shows what it shows. I'm so amazed that hip surgeons, and staff don't know more about pelvic pain. Last time I checked the hip was part of the pelvis... ha!

I'm curious, after you got the steroid injection, how was your central sensitization pain? Any changes?

You are in my prayers, and keep us informed.
take care,
Debbie

Regarding going through PT currently, my PT has me doing hip strengthening exercises i.e. clamshells, bridges with a band around my knees, leg lifts, etc...these really seem to exacerbate the 'posterior groin pain' which is a major pain source for me....(pain to the left of perineum pressing up and back to inside sits bone) which is crazy tender on palpation...this pain exacerbates vulva and left vag wall.

Anyway

Jackie, what types of exercises does your PT have you doing that doesnt aggravate your PN pain?

I am no PT but maybe these exercises should be slightly easier ones?
IF you can handle them, or rather handle the added PN/sit bone pain for a few more sessions, by all means go for it but I would strongly consider at least reducing the load if this pain persists.
I know that in my case at least, I will always get back to base line pain if I have overdone it. It may take some time but it always happens. So while others may say stop now, I will 'experiment' to try acertain exactly what can set which pain off or make it worse (not a masochist, truly) and don't really know how else to evaluate these things. However, I would hope hips can be strengthened with exercises that would not affect the particular area you mention. I wouldn't think that 'ordinary' people, would get additional pain there, with the exercises you describe.
Take care,
Helen

Thanks Jackie, I am "happy" to at least have something objective that can be seen on an MRI, but I know it is possible I could have a hip scope and still widespread chronic pain like I do now unfortunately. I am not sure surgery is even an option like I said because the nurse pracititioner doesn't seem to think labral tears have to be repaired. I worry about surgery anyway (even though I'd much rather have a hip scope than PN decompression!) because of the possibility of worsening central sensitization - if that's what I truly have going on. I also worry about my lack of access to a good PT. I know I would need consistent pelvic/ortho PT for months. I would likely have to spend time away from my family to rehab which I am not thrilled about, but obviously if it helped it would be worth it.

Hey Debbie, I'm on day 5 post steroid injection and I can't say that I've felt any improvement really. In fact I've had an increase in groin/quad burning and PN pain, but I'm not sure that it's related to the injection as of course I flare at random times. The groin/quad burning seems to be directly related to tight muscles in my legs though because massage and warm baths do help it. Unfortuantely I wasn't having the burning when I had the injection so I couldn't tell if the anesthetic took that pain away (though it did take away just the general groin pain with knee flexion and internal rotation), but it seems to be related to the hip and the muscle compensation that is happening. The pain/burning is bilateral though so it will be interesting to see if I have a tear in my right hip or not (I think when I call back in 2 weeks I'm going to ask for a right hip MRI as well) - i guess if I don't have a tear in the right labrum, it would make me wonder a little more about whether the hip is the pain generator of my groin/quad burning or if something like central sensitization/nerve cross talk is to blame. I'll tell you one thing this hip injection was NOTHING compared to other injections I've had. I was barely even sore around the injection site. That's why I wonder sometimes if I do truly have central sensitization because an injection like that often increases people's pain who have CRPS/central sensitization. I have been offered Ketamine infusions by a pain doctor locally though I have some concerns about it because he doesn't seem to do it all the time and I want to make sure it's done right. Though I know the risk is pretty low as compared to other things I've tried. And of course insurance won't pay for it. But I'm thinking about trying it before I consider hip surgery just to see.

Diane, the area that you are describing sounds like posterior alcokc's canal to me. This is where virtually all of my PN pain is. I have to agree with Helen, you might want to back off a little on the exercises. It's likely flaring up your pudendal nerve and that's what I am afraid of as well with hip exercises.

I wanted to make another point. My groin/upper quad burning is worse a week prior to and during my period. I asked some ladies on other hip forums and several people said they had burning in this area around menstruation as well. I think with me that it must be due to increased hypermobility around menstraution. I already have some generalized hypermobility which I feel like might be the cause of my labral tear. This hypermobility definitely complicates things and can affect the success of a hip scope. I am trying to read up on it, but it is all very confusing and especially when you have multiple issues like myself.

This week I've had a lot of burning in my legs altogether when I lie on my side (the only way I can lie) with a pillow between my legs. my legs burn and anything touching them (even the pillow - thankfully not clothes though) seem to irritate them. I am skeptical this is coming from my hip even though I've read that the labrum is highly innervated - not sure what nerves though. Of course I guess my hip could be the pain generator for the whole CNS spiral. If this doesn't get better after my period is over I think I will be even more apt to try the Ketamine/lidocaine infusion before I even think about a hip scope. I feel like I would likely need Ketamine after the surgery anyways to prevent further central sensitization from spreading.